Individual Registration | Rebuilding Hope In New Orleans

Step 1 of 3

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Basic Info
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Email*
Date of Birth*
Please describe your experience level*
Do you have any physical restrictions on site?*
(e.g. cannot lift anything over 30 lbs, sensitive to heat, etc.)
Do you have any medical conditions that we need to be aware of that would affect your ability to work on a construction site?*
We can be assign volunteer tasks if we know this information ahead of time.
In case of emergency, please contact
Emergency Contact Name*
First Last
Emergency Contact Relation*
Emergency Contact Home Phone*
Emergency Contact Cell Phone*
Emergency Contact Email
The following information may be needed by any hospital or medical practitioner not having access to the Volunteer’s medical history:
Allergies (medicines,food,etc)*
Medications being taken*
Date of last tetanus shot*
Physical impairments*
Other

Health Insurance Coverage
Health Insurance Company*
Health Insurance Policy Number*
Health Insurance Emergency Phone
Copy health insurance card*
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Copy of COVID-19 vaccination record card*
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Copy of COVID-19 vaccination record card*
Drop files here or

Accepted file types: jpg, gif, png, pdf.
*A copy of your health insurance card must be supplied along with this completed form.
1. I acknowledge that I have voluntarily applied to St. Charles Ave Presbyterian Church, Rebuilding Hope in New Orleans (SCAPC RHINO) to participate in construction and other activities at various locations in southeastern Louisiana.

2. As consideration for being permitted by SCAPC RHINO to participate in these activities and use their tools and facilities, I hereby agree that I , my assignees, my heirs, distributes, guardians, and legal representatives will not make a claim against, sue, or attach the property of SCAPC RHINO, or the suppliers of any of the tools or equipment I will use in these activities, for injury or damage resulting from the negligence or other acts, howsoever caused, by any employee, agent, contractor of or other participant in SCAPC RHINO activities.

3. I hereby release SCAPC RHINO from all actions, claims, and demands that I, my assignees, my heirs, distributes, guardians and legal representatives now have or may hereafter have for injury or damage resulting from my participation in any SCAPC RHINO activities.

4. I hereby release and forever discharge SCAPC RHINO from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or participation in SCAPC RHINO construction.

5. I understand that SCAPC RHINO does not carry or maintain health or disability insurance coverage for any volunteer. EACH VOLUNTEER IS EXPECTED AND ENCOURAGED TO ARRIVE WITH HEALTH INSURANCE COVERAGE IN EFFECT.

6. I expressly agree that this release is intended to be as broad and inclusive as permitted by the laws of the State of Louisiana and that this release shall be governed by and interrupted in accordance with the laws of the State of Louisiana. I agree that if any clause or provision is ruled invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions for this release, which shall continue to be enforceable.

7. I AM AWARE THAT CONSTRUCTION IS A HARZARDOUS ACTVITY. I AM VOLUNTARILY PARTICIPATING IN THE ACTIVITIES OF CONSTRUCTION WITH THE KNOWLEDGE OF THE DANGER INVOLVED AND WITH THE KNOWLEDGE THAT MEDICAL FACILITIES MAY NOT BE AVAILABLE IN THE EVENT OF INJURY TO ME. I HEREBY AGREE TO ACCEPT ANY AND ALL RISTKS OF INJURY AND DEATH, AND VERIFY THIS STATEMENT BY PLACING MY INITIALS BELOW.

8. If there is any violation of this agreement and SCAPC RHINO is sued, or a claim is made against SCAPC RHINO, I agree to indemnify SCAPC RHINO and the others named in paragraph 2 and hold them harmless from any and all expense and liability. Such indemnity shall cover all reasonable expenses incurred by them, including but not limited to attorney fees.
By placing your initials below you agree to the above terms and condiations*

Authorization and Release
I hereby grant to ST.CHARLES AVE PRESBYTERIAN CHURCH, REBUILDING HOPE IN NEW ORLEANS (SCAPC RHINO), its legal representatives, successors and assigns, irrevocable permission to take and to copyright, in its own name or otherwise, and re-use, publish and republish photographic portraits, pictures or similar images or likenesses (collectively, the “Pictures”) of me and my children and/or other minors for which I am legally responsible, including, without limitation, any other Pictures in which I or they may be included, in whole or in part, composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or fictitious name(s), or reproductions thereof in color or otherwise, made through any medium, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, and any other purpose whatsoever. I also consent to the use of any published matter in connection therewith. The Pictures may be published in any manner, including advertising, periodicals, trade show exhibits, and other promotional applications. Furthermore, I will hold harmless SCAPC RHINO, its representatives, successors and assigns, from any liability arising from or in connection with the aforementioned Pictures.

I affirm that I am more than 18 years of age and that I am competent to sign this contract on my own behalf. I acknowledge that I have read the foregoing authorization and release and that I fully understand its contents.
Name*
First Last
Todays Date*
Are you over 18?*
- Yes
- No
I HAVE CAREFULLY READ THIS ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND RELEASE AGREEMENT AND I FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME AND ST.CHARLES AVE PRESBYTERIAN CHURCH, REBUILDING HOPE IN NEW ORLEANS. I AM SIGNING THIS DOCUMENT OF MY OWN FREE WILL.
Parental signature is mandatory for volunteers under 18 years of age.
Parent / Legal Guardian Name*
First Last
Parent / Legal Guardian Phone*
Parent / Legal Guardian Signature*
Volunteer Signature*
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Step 1 of 3

Basic Info

In case of emergency, please contact

The following information may be needed by any hospital or medical practitioner not having access to the Volunteer’s medical history:

Health Insurance Coverage

Authorization and Release