IDHS-Serve Illinois is seeking volunteers for January 24th - February 7th to assist residents in the Southern Illinois Region, such as Saline, Jackson, and Williamson Counties, affected by the ice storms.

For any questions please contact:
*Jacob Jenkins, IDHS-Serve Illinois Volunteer Program Manager/Disaster Liasion, jacob.jenkins2@illinois.gov, 217.299.3178

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* 1. Name

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* 2. Email

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* 3. Phone Number

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* 4. Address

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* 5. What is your organization/company affiliation, if any?

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* 6. What is your usual weekly availability?

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* 7. Shift Availability

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* 8. Please describe your experience and skills with disaster relief, if any. Include any experience with chainsaw operation or storm damage removal.

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* 9. Can you lift at least 50 pounds?

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* 10. Serve Illinois Media Consent Release
In return for being allowed to participate in IDHS-Serve Illinois Commission on Volunteerism and Community Service volunteer activities and all related activities, including any activities incidental to such participation (“Volunteer Activities”), the undersigned Volunteer
(hereafter referred to using “I”, “me”, or “my”) hereby grants to IDHS-Serve Illinois Commission on Volunteerism and Community Service and each of its subsidiaries,
affiliates, agents, advertising or promotional agencies, and partners, and all such entities’
officers, directors, agents, employees, respective successors, and assigns (collectively,
“Authorized Parties”), the absolute and irrevocable right and permission to use, publish,
broadcast and/or copyright the use of Volunteer’s name, voice, photograph and/or
likeness, caricature, and personal information, in its current form or as retouched, digitized,
cropped, altered, distorted, or modified in any way, in any and all advertising, promotional, or
other materials based upon or derived from the Volunteer Activities in any manner, in any media
whatsoever for any and all purposes, including by way of example but without limitation
advertising, promoting, or publicizing products and services throughout the universe, in
perpetuity, in any and all media now known or hereafter devised (including without limitation on
the Internet), without additional compensation.
I further agree that anything derived therefrom will be owned solely by the Authorized Parties. I
shall not authorize the use of any print, negative or other copy thereof by anyone other than the
Authorized Parties. I understand that this document is intended to be as broad and inclusive as
permitted by the laws of the state in which the Volunteer Activities take place and agree that if
any portion of this Agreement is invalid, the remainder will continue in full legal force and effect.

Volunteer Waiver
In return for being allowed to participate in IDHS-Serve Illinois Commission on Volunteerism and Community Service volunteer activities and all related activities, including any activities incidental to such participation (“Volunteer Activities”), the undersigned (hereafter referred to using “I”, “me”, or “my”) releases and agrees not to sue the IDHS-Serve Illinois Commission on Volunteerism and Community Service) or its officers, directors, employees, sub-contractors, sponsors, agents, and affiliates from all present and future claims that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death arising as a result of my participation in the Volunteer Activities wherever, whenever, or however the same may occur.
I understand and agree that IDHS-Serve Illinois Commission on Volunteerism and Community Service are not responsible for any injury or property damage arising out of the Volunteer Activities, even if caused by their ordinary negligence or otherwise. I understand that participation in the Volunteer Activities involve certain risks, including, but not limited to, serious injury and death. I am voluntarily participating in the Volunteer Activities with knowledge of the danger involved and I agree to accept all risks of participation. I also agree to indemnify and hold harmless IDHS-Serve Illinois Commission on Volunteerism and Community Service for all claims arising out of my participation in the Volunteer Activities. I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the Volunteer Activities take place and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect. I also acknowledge that IDHS-Serve Illinois Commission on Volunteerism and Community Service have not arranged and do not carry any insurance of any kind for my benefit or that of, guardians, trustees, heirs, executors, administrators, successors and assigns.

I represent that, to my knowledge, I am in good health and suffer no physical impairment that would or should prevent my participation in Volunteer Activities. I also understand that this document is a contract which grants certain rights to and eliminates the liability of the IDHS-Serve Illinois Commission on Volunteerism and Community Service.

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* 11. Signature
I am of legal age and am freely signing this agreement. I have read this form and understand that by signing this form, I am giving up legal rights and remedies.

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* 12. Date Signed

Date

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