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2. City of Pembroke Pines Recreation and Cultural Arts
4. HURRICANE RELIEF VOLUNTEER FORM
6. Adult Volunteer (18 years or older)
8. Date:*
   Date:
10. First Name:*
11. Last Name:*
13. Address1:*
15. Address2:
17. City:*
18. State:*
    -- Select One --AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVTVAWAWVWIWY*US Territories (AS, DC, FM, GU, MH, MP PW, PR, VI)*Outside US
19. Zip:*
21. Phone Number (Cell):*
22. Email Address:*
24. 18 years or older:*
    -- Select One --YesNo
26. Emergency Contact Info:
28. First Name:*
29. Last Name:*
31. Relationship:*
32. Phone Number (Cell):*
34. Primary languages spoken:*
36. Additional languages spoken besides English:*
38. Interests:
40. Please tell us in which areas you are interested in volunteering for our Hurricane Relief Efforts:*

    (Check all that apply)

    1. Food Distribution
    2. Water Distribution
    3. Ice Distribution
    4. Administrative Work
    5. Debris cleanup (Parks)
    6. Phone bank (Incoming Calls)
    7. Home (Wellness Checks)
    8. Other
42. Please indicate days available:*

    (Check all that apply)

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
    6. Saturday
    7. Sunday
46. I understand that I am volunteering to serve the City of Pembroke Pines without any expectations of receiving compensation for my time and effort.
48. Release of Liability
50. For good and valuable consideration in the amount of ten dollars ($10.00), as well as being permitted to participate in hurricane relief efforts for The City of Pembroke Pines. Volunteer, and my successors, heirs, assigns, executors, administrators, legal representatives, employees, agents, and affiliates (and in the case of a corporation, and its officers, directors, and shareholders) (collectively referred to as Volunteer), forever release and discharge The City of Pembroke Pines, and each of its officers, elected officials, directors, employees, agents, and affiliates (collectively referred to as The City of Pembroke Pines) from all claims, demands, obligations liabilities, causes of action and judgements whatsoever, in law or in equity, which against and of the foregoing, any or all of Volunteer ever had, now has or which they hereinafter can, shall or may have for, upon or by reason of any matter, cause or thing whatsoever arising out of Volunteer’s involvement in the Event. Volunteer agrees to and does hereby assume any and all risks of personal injuries to Volunteer, including death, and damages to Volunteer’s person or property, caused by or arising out of involvement in the Event. Volunteer hereby agrees to defend, indemnify and hold The City of Pembroke Pines harmless from and against any claim, demands, suit, loss, causes of action, damages, liabilities, obligations, attorney’s fees, costs, expenses, and judgements (including without limitation, death, and damages to property) caused by Volunteer’s acts or omissions and arising out of Volunteer’s involvement in the Event. As a volunteer you assume all risk and should not attend any event in which your participation or transportation to and from the event would endanger yourself or others.
52. THE VOLUNTEER HAS READ AND UNDERSTANDS THE FOREGOING RELEASE AND INDEMNIFICATION AND HAS SIGNED IT VOLUNTARILY.
54. Agreement Disclaimer*

    1. Agree

    By checking this box you are agreeing to all terms and conditions set forth by the City of Pembroke Pines to volunteer
56. Full Name*
58. If you have any questions, please call (954)392-2130 or email Carol Campisi, Assistant Director of Recreation and Cultural Arts @ ccampisi@ppines.com
60. 
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field