Ubuntu Legacy Community Care

Waiver Form

Thank you for your interest in participating/volunteering with Ubuntu Legacy Community Care! All participants/volunteers MUST have a signed waiver in order to participate in program activities. If you are under 18 years old, please complete this form with the help of a parent or guardian.

Participant Information

Please complete all required fields marked with an asterisk (*)

1. Participant Type

Choose one of the options below: *

I am over the age of 18 and will be completing this form for myself.

I am the legal parent/guardian of a minor participant and will be completing this form on their behalf

2. Contact Information

First and last name of the person completing this form: *

Email address: *

Phone number: *

Emergency contact name and phone number: *

Secondary emergency contact (optional):

3. Communication Preferences

Do you wish to subscribe for newsletter or updates from Ubuntu Legacy Community Care? *

YES! Sign me up to receive monthly updates on Ubuntu Legacy events and volunteer opportunities.

No, I do not want to subscribe for emails

Maybe

4. Health & Accessibility Information

If the participant/volunteer has any physical or health concerns which we should be aware of to provide accommodation, please list concerns below:

If the participant/volunteer has any severe allergies to food or other substances, please list concerns below:

If the participant/volunteer has any health concerns that needed to be addressed or mobility issues like wheelchair, walker, please list concerns below:

Any other concerns that may affect the participation of participant/volunteer?

Do you need shuttle service from your place? *

Yes

5. Program Information

Which session do you plan to attend? *

How did you hear about this event? *

How would you like to receive additional information about the event? *

6. Informed Consent & Assumption of Risk and Waiver of Liability

Please read the following carefully:

I have read and understood the information provided in this form about participating/volunteering for Ubuntu Legacy Community Care. I hereby willingly consent to release Ubuntu Legacy Community Care (ULCC) from all liabilities and waive all claims and demands arising from personal injuries I (or the participant/volunteer if under 18 years of age) may incur while participating/volunteering with ULCC.
I understand that photographs and/or videos may be taken of myself (or the participant/volunteer if under 18 years of age) and may be used in the promotion of Ubuntu Legacy Community Care (ULCC). They may be published or used for any application in newspapers, magazines, film, television commercials, posters, slide presentations or otherwise displayed to the public or used for educational, fundraising, information or training purposes.
I understand that I will not receive any compensation for photographs or videos taken of myself (or the participant/volunteer if under 18 years of age) during ULCC activities.
ULCC is committed to fostering a safe, inclusive, and welcoming environment through our programming. All participants/volunteers are expected to uphold our value of inclusivity and not engage in behaviours or actions that are discriminatory or may be perceived as discriminatory by others. Violation of this policy may result in discipline including removal from the program at the discretion of ULCC.
By providing your contact information, you consent to ULCC using it in accordance with our privacy policy which is available to review by downloading ourPrivacy Policy & Terms of Use (PDF). We will not, without consent, use your personal information for any purpose other than described in our privacy policy. Please note third-party service providers may be engaged by ULCC to perform a variety of functions, such as mail you information, process your donation/fees, or provide technical services for our website or information systems. These third-party providers may have access to personal information if needed to perform the functions for which they were retained. However, in cases when information is shared, ULCC will obtain reasonable assurance that the third parties will protect your information in conformity with our privacy practices.

I have read the Informed Consent & Assumption of Risk and Waiver of Liability. By checking this box, I confirm that I understand and accept the legal consequences of my participation. *

Accepted by (please provide your full name below): *

Date of Consent: *