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Your information


Required fields are marked with an asterisk (*).
Birthdate *

A valid date as MM/DD/YYYY (for example: 11/30/2015)
First Name *
Last Name *
Volunteer Type *
Group/Organization Name
In what ways would you like to volunteer? *




Gender *
Street Address *
City *
State *
Zip *
Preferred Phone Number *
Emergency Contact First Name *
Emergency Contact Last Name *
Emergency Contact Relationship *
Emergency Contact Phone Number *
Do you have medical insurance? *
If injured, can we seek medical attention, including transportation to the emergency room? *
Do you give the GMFB, its designees, agents and assigns unlimited permission to use, publish and republish in any form or media, information about you and reproduction of your likeness (photographic or otherwise) any your voice, with or without identifica *

Waiver

In conjunction with my voluntary involvement in activities undertaken for, and with the participation and support of the Georgia Mountain Food Bank, a non-profit charitable organization, I hereby agree, for myself, my heirs, my assigns, executors, and administrators to release and discharge the Georgia Mountain Food Bank , its officers and directors, employees, agents, and volunteers from all claims, demands, and actions for injuries sustained to my person and/or property as a result of my involvement in such activities, whether or not resulting from negligence, and I agree to release and hold the Georgia Mountain food Bank, its officers and directors, employees, agents and volunteers harmless from any cause or action, claim or suit arising therefrom. I hereby attest that my attendance and involvement in such activities is voluntary, that I am participating at my own risk, and that I have read the foregoing terms and conditions of this release.

I also agree to report to the person in charge:
Any onset of the following symptom, either while at work or outside of work, including the date of onset:
- Diarrhea -Jaundice
-Vomiting -Sore throat with fever
-Infected cuts or wounds, or lesions containing pus on the hand, wrist, an exposed body part, or other body part and the cuts, wounds or lesions are not properly covered (such as boils and infected wounds, however small)
Future medical diagnosis:
Whenever diagnosed as being ill with Norovirus, Typhoid Fever (Salmonella Typhi), Shigellosis (Shigella spp. infection), Escherichia coli O157:H7 or other STEC infection, nontyphoidal Salmonella, or hepatitis A (hepatitis A virus infection)
Future exposure to foodborne pathogens:
1: Exposure to or suspicion of causing any confirmed disease outbreak of Norovirus, Typhoid Fever, Shigellosis, E. Coli O157:H7 or other STEC infection, or Hepatitis A.
2: A household member diagnosed with Norovirus, Typhoid Fever, Shigellosis, illness due to STEC or Hepatitis A.
3: A household member attending or working in a setting experiencing a confirmed disease outbreak of Norovirus, Typhoid Fever, Shigellosis, E. Coli O157:57 or other STEC infection, or Hepatitis A.
I have read and understand the requirements concerning my responsibilities under the Georgia Food Service Rules and Regulations Chapter 511-6-1 and this agreement to comply with:
1: Reporting requirements specified above involving symptoms, diagnoses, and exposure specified;
2: Work restrictions or exclusions that are imposed upon me; and
3: Good hygienic practices.

I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the Health Authority that may jeopardize my tenure and may involve legal action against me.