Participant Form

Volunteer Application

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Campaign ID

Reservation ID

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Group Week Information

Before you proceed please confirm that the following details about your group and the scheduled group week are correct. If you have questions or if you need assistance completing this participant form please contact the primary contact for your organization, their contact information should be listed below.

Organization Name:

Group Week:

Arrival Date:

Primary Contact:

Primary Contact Phone:

Is this your organization, and the correct group week?

YesNo

Oops Something Went Wrong!!!

If the above details are not correct please contact your organizations primary contact, or return to the email you received and try the link again. If you are still having trouble contact community@jerusalemfarm.org or 816-421-1855

Volunteer Contact information

First Name

Last Name

Date of Birth

Legal Age

I am under 18I am 18 or older

Phone Number

Phone Type:

Email Address

Email Type:

Class

Role within Organization:

Volunteer Mailing Address

Street Address

City

State

Please use two letter state code

Postal Code

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Parent or Guardian Contact Information

First Name

Last Name

Date of Birth

Phone Number

Phone Type:

Email Address

Email Type:

Parent or Guardian Mailing Address

Street Address

City

State

Postal Code

Hidden parent contact lookup

parent phone lookup

parent email lookup

parent address lookup

Affiliation information

If a questions does not apply to you, just type "none"

Home Parish, if applicable

Home Diocese, if applicable

Have you visited Jerusalem Farm before?

YesNo

If so, please explain!

Volunteer agreement

I am fully aware that the volunteer experience at Jerusalem Farm will require me to make personal sacrifices of which I may not be accustomed. I agree to live this week in simplicity, doing without some of the conveniences to which I am accustomed. I will work and complete tasks to the best of my ability.

I realize that living and working together in community will require me to display patience and respect toward all members of the group.

I realize the importance of following a schedule and the guidance and instruction of the leaders.

I am willing to comply with the requests of the leadership and be flexible with what is asked of me.

I am aware that the week will involve a focus on prayer based on the Catholic tradition. I am open to this experience and will actively participate to the degree which I am able.

I further realize that I will be visiting an area where the culture and the customs may differ from my own. I will treat all people at the Farm and in the surrounding community with respect.

I agree not to involve myself in drugs, alcohol, or sex while at Jerusalem Farm.

I give consent for Jerusalem Farm to videotape and photograph me during my volunteer week. I understand these photographs and videotapes may be used for advertising and/or orientation materials for Jerusalem Farm including the JFarm website. I give my permission for possible participation in videotaping and/or still photographs.

During my group week, I give consent for Jerusalem Farm to post my address, in order to confirm and/or correct my mailing address and email contact information.

I dedicate myself to be an active participant in this week of service, prayer, simplicity, and community as an experience of Christian living.

Electronic Signature of Volunteer:

Please type your name here as your digital signature.

Electronic Signature Agreement:

By signing above, I acknowledge and agree that (a) it is my intent to sign this electronic record and be legally bound thereby, (b) this document will be kept in a retrievable electronic medium and, upon my request, will also be kept in a retrievable tangible medium, (c) I have the right to request and receive a digital or tangible copy of this electronic record at any time, and (d) I am not required to sign this document in a digital form, but instead may sign a physical copy in lieu of this digital one if I so desire and request.

I understand and agree that this contract and my signature are in full force and effect and cannot be denied legal effect, validity, or enforceability solely because it is in electronic form.

Any notice or request required or permitted to be given to Jerusalem Farm shall be effective only if in writing and sent by certified mail, or commercial messenger service, to Jerusalem Farm, 520 Garfield Avenue Kansas City, Missouri 64124

Health Insurance/Medical Release Form

Volunteer Emergency Contact Information

Volunteer's Emergency Contact Person

Emergency Contact's relationship to Volunteer

Emergency Contact's Primary phone

Emergency Contact's Secondary phone

Medical Information

If a questions does not apply to you, just type "none"

Allergies

Dietary Restrictions (vegetarian, food allergies, etc.)

Current Medications

Will you need assistance with your medication(s)? Please specify.

Blood Type (if known)

Date of most recent TETANUS BOOSTER

Limitations to physical labor

(You will NOT be made to perform any task you are unable to do for whatever reason.)

Are you comfortable riding a bike?

YesNo

Emotional/Psychological condition(s) and/or concerns

Have you received the COVID-19 vaccine?

YesNo

Insurance Information

Complete name of Insurance Company:

Policy Number/Group Number:

Name on Insurance Card:

Cardholder's Date of Birth

(If you do not have health insurance, please contact us at 816-421-1855 or volunteer@jerusalemfarm.org)

Statement of Validity and Responsibility

I, the undersigned, accept financial responsibility for any medical fees that occur either during or after my stay at Jerusalem Farm. In addition, I certify that the above emergency contact, medical, and insurance information is correct.

Electronic Signature of Volunteer:

For Parents or Guardian if Volunteer is under 18:

During the volunteer’s week here at Jerusalem Farm, she or he will ride in vans to and from worksites. Because parish/school groups are broken up into work groups, it is very likely that your child will ride in a van driven by an adult chaperone other than your child’s group leader. All vans will only be driven by adult chaperones during the week.

I, the undersigned parent or guardian of the volunteer who has signed above, a minor, do hereby authorize the adult staff members of Jerusalem Farm as my agents, to consent to any examinations, x-ray, anesthetic, medical, or surgical diagnosis or treatment and hospital care which is deemed advisable by a qualified physician or local hospital. Jerusalem Farm agrees to contact the undersigned as soon as possible if an emergency should arise. I will assume responsibility for fees incurred by such an emergency. In addition, I certify that the above information is correct and give permission for the release of medical records to the attending physician.

Electronic Signature of Parent or Guardian:

Please type your name here as your digital signature.

Electronic Signature Agreement:

By signing above, I acknowledge and agree that (a) it is my intent to sign this electronic record and be legally bound thereby, (b) this document will be kept in a retrievable electronic medium and, upon my request, will also be kept in a retrievable tangible medium, (c) I have the right to request and receive a digital or tangible copy of this electronic record at any time, and (d) I am not required to sign this document in a digital form, but instead may sign a physical copy in lieu of this digital one if I so desire and request.

I understand and agree that this contract and my signature are in full force and effect and cannot be denied legal effect, validity, or enforceability solely because it is in electronic form.

Any notice or request required or permitted to be given to Jerusalem Farm shall be effective only if in writing and sent by certified mail, or commercial messenger service, to Jerusalem Farm, 520 Garfield Avenue Kansas City, Missouri 64124

Release and Waiver of Liability

This Release and Waiver of Liability (the "Release") executed on this day:

By:

Release

In favor of Jerusalem Farm, a non-profit corporation organized and existing under the laws of the State of Missouri, USA, its directors, officers, employees, agents, successors and assigns (“Jerusalem Farm” herein).

The individual desires to volunteer for Jerusalem Farm and engage in the activities related to being a volunteer (the “Activities”). I, the volunteer hereby freely and voluntarily, without duress, execute this Release under the following terms:

1. Waiver and Release. I, the volunteer release, forever discharge, indemnify and hold harmless Jerusalem Farm from any and all liability, claims, and demands of whatever kind or nature, either in law of in equity, which arise or may hereafter arise from the Activities at Jerusalem Farm. I, the volunteer understand and acknowledge that this Release discharges Jerusalem Farm from any liability or claim that I, or my guardians or successors may have against Jerusalem Farm with respect to bodily injury, personal injury, illness, death, and/or property damage that may result from my Activities with Jerusalem Farm, whether caused by the negligence of Jerusalem Farm or otherwise. It is also understood that Jerusalem Farm 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, illness, death, or property damage.

2. Insurance. I, the volunteer understand that Jerusalem Farm does not carry or maintain health, medical, or disability insurance coverage for any volunteer. I expressly waive any such claim for compensation or liability on the part of Jerusalem Farm in the event of such injury or medical expense.

3. Medical Treatment. I, the volunteer hereby release and forever discharge Jerusalem Farm from any claim whatsoever which arises or may hereafter arise on account of any first aid treatment or other medical services rendered in connection with my Activities with Jerusalem Farm.

4. Assumption of Risk. I, the volunteer understand that the time with Jerusalem Farm may include activities which may be hazardous to me including, but not limited to, construction activities, use of power tools, use of cutting tools, loading and unloading of heavy equipment and materials, climbing ladders and transportation to and from work sites. Also I, the volunteer recognize and understand that the time with Jerusalem Farm may, in some situations, involve inherently dangerous activities. These potential dangers are part of and inherent to the activity I am going to engage in and in some instances the activities cannot be made safer. As the volunteer, I hereby expressly assume the risk of injury or harm in these activities and release Jerusalem Farm from all liability for injury, illness, death, or property damage resulting from these activities. I further assert and agree that I will adhere to all instructions given to me by Jerusalem Farm.

5. Photographic and Statement Release. As the volunteer, I grant and convey unto Jerusalem Farms all right, title, and interest in any and all photographic images, video or audio recordings, and statements or writing made by or to Jerusalem Farm during my Activities with Jerusalem Farm (the “Materials”), including, but not limited to, any royalties, proceeds, or other benefits derived from such materials. I grant Jerusalem Farm the unrestricted right and permission to use the Materials for any lawful purpose whatsoever. I waive any right of publicity or privacy I might have with respect to such Materials.

6. Other. As the volunteer I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Missouri in the USA, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Missouri. I agree 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.

To express my understanding of this release, I sign here.

Electronic Signature of Volunteer:

Please type your name here as your digital signature.

Name of School/Church/Organization:

If volunteer under 18 years of age (minor), the Release and Waiver of Liability must also be signed by a parent or guardian.

Electronic Signature of Parent/Guardian:

Please type your name here as your digital signature.

Electronic Signature Agreement:

By signing above, I acknowledge and agree that (a) it is my intent to sign this electronic record and be legally bound thereby, (b) this document will be kept in a retrievable electronic medium and, upon my request, will also be kept in a retrievable tangible medium, (c) I have the right to request and receive a digital or tangible copy of this electronic record at any time, and (d) I am not required to sign this document in a digital form, but instead may sign a physical copy in lieu of this digital one if I so desire and request.

I understand and agree that this contract and my signature are in full force and effect and cannot be denied legal effect, validity, or enforceability solely because it is in electronic form.

Any notice or request required or permitted to be given to Jerusalem Farm shall be effective only if in writing and sent by certified mail, or commercial messenger service, to Jerusalem Farm, 520 Garfield Avenue Kansas City, Missouri 64124