KIDS' Night Volunteer Sign Up * indicates required field Title:* Select one: Ms. Mr. First Name:* Last Name:* Address:* City:* State:* Zip Code:* Email:* Cell Phone:* Date of Birth:* KIDS' Night Details: Which KIDS' Night date(s) would you like to volunteer at:* March 26 April 23 May 21 June 25 July 23 August 20 September 17 October 15 November 12 December 10 Age Group Preference: Ages 3-8 Ages 9-16 Please note we will do our best to place you according to your preference, but we ask for your flexibility as we strive to create the best environment for the children, families, and volunteers. T-Shirt Size S M L XL 2XL 3XL Optional: If you have any special strengths or experience that you feel would be beneficial for us to know, please share below (ex. teacher, therapist, coach, previous experience with kids with special needs): Are you volunteering with a Church, Company, or Organization?* yes no If yes, please type the name of the organization you are volunteering with: Please provide two references: Reference 1 Name:* Title/Organization: Relationship to you:* Phone:* Email: Reference 2 Name:* Title/Organization: Relationship to you:* Phone:* Email: Waivers Release of Liability: There is an inherit risk associated working with children and more so with special needs children. Nonetheless, I assume all related risks, both known or unknown to me, of my participation in KIDS' Night. I understand that injuries or outcomes may arise from my or other’s actions, inaction, or negligence; or the condition of the Activity location(s). I release from all liability and promise not to sue One Child Center for Autism, the Williamsburg Indoor Sports Complex(WISC), and their employees, officers, directors, volunteers and agents (collectively “One Child”) from any and all claims, including claims of One Child’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss that may occur because of participation in this Activity. I understand the legal consequences of this agreement, including (a) releasing One Child from all liability, (b) promising not to sue on my behalf, (c) and assuming all risks of the participation in KIDS' Night.* COVID-19 information: While participating in events held or sponsored One Child Center for Autism consistent with CDC guidelines, participants are encouraged to practice hand hygiene, “social distancing” and wear face coverings to reduce the risks of exposure to COVID-19. Because COVID-19 is extremely contagious and is spread mainly from person-to-person contact, one child center for autism has put in place preventative measures to reduce the spread of COVID-19. However, cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with COVID-19. In light of the ongoing spread of COVID-19, individuals who fall within any of the categories below should not engage in Kids’ Night events and/or other face to face activities. By attending an Kids Night, you certify that you do not fall into any of the following categories: 1. Individuals who currently or within the past fourteen (14) days have experienced any symptoms associated with COVID-19, which include fever, cough, and shortness of breath among others;2. Individuals who have traveled at any point in the past fourteen (14) days either internationally or to a community in the U.S. that has experienced or is experiencing sustained community spread of COVID-19; or 3. Individuals who believe that they may have been exposed to a confirmed or suspected case of COVID-19 or have been diagnosed with COVID-19 and are not yet cleared as non-contagious by state or local public health authorities or the health care team responsible for their treatment.* Confidentiality Agreement: To protect the identity and privacy of One Child Center for Autism’s (One Child) clients. During the course of your involvement with One Child (hereinafter also referred to as “Disclosing Party”), staff and volunteers (hereinafter also referred to as “Receiving Party”) will encounter personal and sensitive information about One Child’s clients; this is particularly true when assisting children with Autism who often are accompanied by significant medical conditions and behaviors. It is, therefore, very important to refrain from disclosing any information to third parties about One Child’s clients. In order that One Child may disclose confidential information to staff and volunteers, all staff and volunteers agree to the following terms: (1)As used in this Agreement, “Confidential Information” means any information furnished by the Disclosing Party to the Receiving Party in furtherance of the Purpose and in connection with the Purpose, regardless of whether such information is specifically designated as confidential and regardless of whether such information is in written, oral, electronic, or other form. Such Confidential Information shall include, without limitation, any information that would identify the client, including the client’s name, address or phone number, information relating to the client’s family, information regarding the client’s medical diagnosis or other medical conditions and information about the abuse, trauma, and/or persecution experienced by the client or family members; (2) Receiving Party agrees that it shall maintain all Confidential Information in strict confidence; (3) The obligations set forth in this Agreement shall always remain in effect, including after separation from One Child. I consent to the execution of this agreement.* Audio/Video Release: I hereby grant One Child Center for Autism permission to use my likeness in any photographic, motion picture, electronic images, to include sound and video recordings. I waive the right to receive any payment, inspect, or approve the eventual use of my likeness as described above. All permissions and waivers described above will continue until revoked in writing.* Email Sign Up Please add me to the One Child Volunteer Email List to receive monthly updates.
