Single | MOMM

Name *

First Name

Last Name

Residence Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Employer's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer's Phone *

(###)

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Previous Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Employer's Phone *

(###)

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Skills, experience, and interests *

Check all that apply

Finance, accounting

Personnel, human resources

Administrative, management

Nonprofit experience

Community service

Policy development

Program evaluation

Education, instruction

Special events

Grant writing

Legal services

Fundraising

Outreach, advocacy

Other (please list below)

Release and Waiver of Liability *

By checking this box, I am in agreement of the following: In consideration for the participation of helping Single MOMM, the undersigned (Volunteer/Board Member). Hereby agrees to donate and offer his/her personal services and labor, free of charge, to Single MOMM. Undersigned understands and agrees that they are not an employee of Single MOMM and are not entitled to any wages and/or benefits associated with their services. Board Member/Volunteer acknowledges and understands that the activities include work that may be hazardous to the undersigned, including but not limited to, loading/unloading materials, transportation to and from any venue, caring for children, working in a kitchen setting, and serving hot liquids Undersigned further agrees, on behalf of himself/herself and on behalf of his/hers heirs, assigns, trustees, receivers, administrators, executors, and agents to release and forever discharge Single MOMM, their directors, officers, employees, agents, volunteers, invitees, sponsors, cash donors, in-kind donors, contractors, and all other personas or entities whomsoever (Single MOMM(, of and from any and all actions, claims, and demands, known and unknown which Board Member/Volunteer has or may have in the future arising out of volunteering for Single MOMM. Additionally, undersigned specifically releases any subrogation rights that might arise. Undersigned understands that this Release discharges Single MOMM for any liability or claim that the Board Member/Volunteer may have against Single MOMM with respect to any bodily injury, personal injury, illness, death or property damage that may result from Undersigned activities with Single MOMM whether caused by the negligence of Single MOMM or its officers, directors, employees, or agents or otherwise. Undersigned understands that Single MOMM 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. Undersigned does hereby grant and convey unto Single MOMM all right, title, and interest in any and all photographic images and video or audio recordings made by Single MOMM during the Undersigns’ work for Single MOMM including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. The Undersigned acknowledges that he/she has read this Release and understands that this Release may be pled as a complete bar and defense to any action or other proceedings instituted or filed by Undersigned on account of any matter contained herein. Undersigned expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of Michigan and that this Release shall be governed by and interpreted in accordance with the laws of Michigan. Undersigned 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 authorize, at Single MOMM’s discretion, investigation of all statements made by me in this application, and review of any civil or criminal records which may exist, concerning me, except for such records as are sealed according to state or federal law.

By checking this box, I am in agreement of the following: I further authorize Single MOMM at its discretion, to contact references and others whose names are provided on this application form, or whose names, may be identified by me in an interview, and I authorize such person to provide Single MOMM with information requested by Single MOMM regarding me. I further release any such individuals, as well as Single MOMM for any claims I might have arising out of any discussions involving me, or the provision of any information or records regarding me.

By checking this box, I am in agreement of the following: Board Member/Volunteer Responsibility: If for any reason I believe that my working as a Board Member/Volunteer for Single MOMM might endanger myself or others or I have knowledge of or suspect any dishonest, deceptive, illegal or unethical activities, I must report this to the Executive Director immediately and at the site, and the Single MOMM employee overseeing the activity. This might include, among other things, improper use of agency property, communicable diseases, physical impairments, medication (prescription and/or otherwise that might impair judgment), and suspected or witnessed child abuse. I am volunteering for Single MOMM at my own risk.

By typing your name below you are agreeing to the above statements and accuracy of information in this document *

First Name

Last Name

Date *

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If you are under 18 years of age

In the event that the above Board Member/Volunteer is less than eighteen (18) years old, this Release must be executed by said minor's parents or legal guardian.

First Name

Last Name

Guardian/Parent

First Name

Last Name

Date

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