Volunteer Application

Volunteer Application

Contact Information

Employment history (if applicable)

Volunteer experience (if applicable)

Tell us about yourself

References

Please provide 2 references, not including relatives.

Informed consent

The above information is true to the best of my knowledge.

I authorize the Corporation of the Town St. Marys, herein known as “The Corporation” to collect, keep, and use my personal information appropriate to the position applied for concerning my employment history and to verify the character references I have supplied. I understand that confidentiality will be respected and no information that discloses my personal information will be released or published without consent unless required by law.

I take much of the information I receive during my volunteer involvement is confidential and will not disclose or release information to any person or agency except where required by law, any information or documents that identify anyone receiving services with the Town of St. Marys. I understand that a breach of client confidentiality may result in my being removed from my volunteer position.

Release of liability, waiver of claims, assumption of risks and indemnity agreement

Read carefully. By signing this document you will waive certain legal rights, including the right to sue.

To: The Corporation of the Town of St. Marys, and its respective elected officials, directors, officers, employees, agents, independent contractors, sub-contractors, representatives, successors and assigns (hereinafter collectively referred to as the “Releasees”):

Release of liability, waiver of claims and indemnity agreement

I agree to waive any and all claims that I have or may have in the future against the Releasees and to release the Releasees from any and all liability for any loss, damage, expense or injury including death that I may suffer or that my next of kin may suffer as a result of my involvement in the above noted program or event DUE TO ANY CAUSE WHATSOEVER, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE OWED UNDER THE OCCUPIERS LIABILITY ACT, R.S.O. 1990, C.O.2, AS AMENDED, ON THE PART OF THE RELEASEES, AND INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS OF PARTICIPATION IN THE NOTED PROGRAM, WHICH RISKS AND HAZARDS INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING:

1. Health:   traumatic injury, bacterial infections, rashes, and the transmission of communicable diseases, including viruses of all kinds, COVID-19, bacteria, parasites or other organisms or any mutation thereof.
2. Premises:  defective, dangerous or unsafe  condition  of  the  facilities;  falls;  collisions  with objects, walls, equipment or persons; dangerous, unsafe, or irregular conditions on grass, turf or other surfaces, extreme weather conditions; travel to and from premises.
3. Use of Equipment and/or supplies: mechanical failure or negligent manufacture or design of equipment or supplies provided by the Releasees; the  provision  of  or  the  failure  by  the  Releasees to  provide  any  warnings, directions, instructions or guidance as to the use of equipment or supplies; failure to use or operate the equipment or supplies within my own ability.
4. Cyber: privacy breaches, hacking, technology malfunction or damage.
5. Conduct: My conduct and conduct of other persons including any physical altercation between participants.
6. Travel: Travel to and from and during my participation in the program.
7. Negligence: My negligence and negligence of other persons, including NEGLIGENCE ON the PART OF THE RELEASEES, may increase the risk of damage, loss, personal injury or death.

Infectious Disease Acknowledgment

Without limiting the generality of the foregoing, I acknowledge that:

1. My participation in program may increase my risk of becoming infected with Covid-19 or any infectious disease and that Covid-19 and many infectious diseases can cause personal injury, illness, permanent disability and/or death.
2. If I am older adult, have a compromised immune system, have a chronic health condition, or regularly go to a hospital or health care setting from treatment of illness, I acknowledge that I am at an increased risk of becoming infected with any infectious disease including Covid- 19 and I choose to participate despite any recommendation from my local and Provincial Public Health Authority.

I agree to comply with the attached Town of St. Marys COVID-19 Rules for Volunteers at all times during my participation in the Program.

I hereby agree TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any property damage or personal injury to any third party resulting from my participation in the Program.

This Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, assigns and representatives, in the event of my death or incapacity.

In entering into this Agreement I am not relying on any oral or written representations or statements made by the Releasees with respect to the safety of the program, other than what is set forth in this Agreement.

I confirm that I have read and understand this agreement prior to signing it, and I am aware that by signing this agreement I am waiving certain legal rights which I or my heirs, next of kin, executors, administrators, assigns and representatives may have against the Town of St. Marys.

If volunteer is under the age of eighteen (18) a parent or guardian is required to sign completed form. The Senior Services Supervisor will advise on process for receiving this.   

Signature of parent or guardian: