ADULT VOLUNTEER REGISTRATION FORM

Note: Please complete all questions. If unknown put N/A.
Sending country:

Team name:

Host country:

Team leader:


Personal Information

Title:

First name:

Middle name:

Last name:

Preferred name:

Gender:
Male    Female

Date Of Birth

Preferred format: dd/mm/yyyy

Occupation:


Current Address

Street number:

Street:

Suburb:

City/Town:

Country:

Postcode:

Type of address:
Home    Home    School    Other


Contact Details

Phone - Home:

Phone - Work:

Mobile:

Email:


General Information

Nationality:

Passport number:

Country issued:

Date issued:

Preferred format: dd/mm/yyyy

English language skill:
Native English Speaker   Good   Poor   None

List construction skill, if you have any:

List church affiliations you might have:


T-Shirt size:


Emergency Contact Information

Contact name:

Relationship:

Address:

Phone (Day):

Phone (Night):

Email:


The following information may be needed by any hospital or medical practitioner not having access to your medical history.

Blood type:

Date of last Tetanus shot:

Preferred format: dd/mm/yyyy

Allergies to medicine, food, bee sting, etc. (please provide any dietary concerns):


Current medication being taken:

Physical impairments:

Personal physicians name:

Physician's address:

Phone (Day):

Phone (Night):

Email:


If you have PERSONAL/SCHOOL HEALTH INSURANCE COVERAGE, please provide the following information

Insurance company:

Insurance agent:

Agent's phone:

Policy number:


I understand that I must purchase and provide information of international travel/medical insurance through MEDEX, Habitat for Humanity International's preferred carrier, for the entire term of my volunteer service with Habitat for Humanity. I certify that the answers I have given are true and correct to the best of my knowledge.

Signature of volunteer:
(please type your name)
Date:


Important: Each participant, including team leaders, must have a signed "Release and Waiver of Liability" on file with Habitat for Humanity prior to departure. Please PRINT all information in blanks provided
PLEASE COMPLETE AND READ CAREFULLY! THIS IS A LEGAL DOCUMENT!
This Release and Waiver of Liability (the "Release") executed on this 10th day of 2th(month), 2012, by (the "Volunteer") in favor of HABITAT FOR HUMANITY INTERNATIONAL, INC., a Georgia nonprofit corporation, HABITAT FOR HUMANITY (hosting Habitat Organization), and HABITAT FOR HUMANITY NEW ZEALAND (sending Habitat organization), an entity formed under the laws of NEW ZEALAND (sending country), their trustees, directors, officers, employees, and agents (collectively, "Habitat").

The Volunteer desires to work as a volunteer for Habitat and engage in the activities related to being a volunteer. The Volunteer understands that the activities may include constructing and rehabilitating residential buildings and living in housing provided for volunteers of Habitat. The Volunteer does hereby freely, voluntarily, and without duress execute this Release under the following terms:

1. Waiver and Release.
Volunteer and Guardian do hereby release and forever discharge and hold harmless Habitat and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from Volunteer's work for Habitat.

Volunteer and Guardian understand that this Release discharges Habitat from any liability or claim that the Volunteer or Guardian may have against Habitat with respect to any bodily injury, personal injury, illness, death, or property damage that may result from Volunteer's work for Habitat, whether caused by the negligence of Habitat or its officers, directors, employees, or agents or otherwise. Volunteer and Guardian also understand that Habitat does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.

2. Medical Treatment.
Volunteer and Guardian do hereby release and forever discharge Habitat from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the Volunteer's work for Habitat or with the decision by any representative or agent of Habitat to exercise the power to consent to medical or dental treatment as such power may be granted and authorized in the Parental Authorization for Treatment of a Minor Child.

3. Assumption of the Risk.
The Volunteer and Guardian understand that the work for Habitat may include activities that may be hazardous to the Volunteer, including, but not limited to, construction, loading and unloading, and transportation to and from the work sites.

Volunteer and Guardian also understand that, in order to protect its employees and volunteers in all countries around the world, it is Habitat’s policy that it will not pay ransom or make any other payments in order to secure the release of hostages. Volunteer and Guardian hereby expressly and specifically assume the risk of injury or harm in these activities and release Habitat from all liability for injury, illness, death, or property damage resulting from the activities of the Volunteer’s work for Habitat.

4. Insurance.
The Volunteer and Guardian understand that, except as otherwise agreed to by Habitat in writing; Habitat does not carry or maintain health, medical, or disability insurance coverage for any Volunteer.

5. Photographic Release.
Volunteer and Guardian do hereby grant and convey unto Habitat all right, title, and interest in any and all photographic images and video or audio recordings made by Habitat during the Volunteer’s work for Habitat, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

6. Other.
Volunteer expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of State of Georgia, of (hosting country) and of NEW ZEALAND (sending country); and that this Release shall be governed by and interpreted in accordance with the laws of the State of Georgia, of (hosting country) and of NEW ZEALAND (sending country). Volunteer agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

I have read and agree with the Terms and Conditions