SATURDAY, APRIL 25, 2015
A 5K Run/Fitness Walk community event celebrating &
supporting over 50 DuPage non-profit organizations
VOLUNTEER RESPONSE FORM
Volunteers are the heart and soul of the Human Race. Your support makes it possible for Giving DuPage to host
the Human Race as a fundraiser for 50+ local non-profit organizations. All volunteers will receive a T-shirt, water
and snacks at the event. Individuals, families, friends and groups are all welcome to volunteer.
Please complete this response form and return it as soon as possible (email & fax instructions below).
NAME:
__________________________________________
PHONE:
EMAIL:
_______________________________________________________
_(______)_______________
AGE:
__________
MAILING ADDRESS:
________________________________________________________________________
(address, city, state, zip)
GROUP VOLUNTEER?
STUDENT?
□Y □ N
□Y □ N
COMMUNITY SERVICE?
NAME OF GROUP/COMPANY:
NAME OF SCHOOL:
□Y □ N
________________________________
GRADE: _____
_________________________________
IF YES, DO YOU NEED COMPLETED SERVICE FORM?
DO YOU HAVE AN OFFENSE/CRIMINAL RECORD FOR CONSIDERATION TO BE A VOLUNTEER?
EMERGENCY CONTACT
NAME:
__________________________________________
PHONE:
□Y □ N
□Y □ N
_(______)_______________
RACE DAY VOLUNTEER OPTIONS (please indicate your 1st, 2nd & 3rd choice of assignments)
____ Anywhere needed
____ Race Day Set-Up
____ Start Line
____ Finish Line
____ Course Marshal
____ Water Station
____ Food Station
____ Parking
PRE-RACE PACKET PICK-UP (please indicate your 1st, 2nd & 3rd choice of assignments)
____ Packet Assembly on Wednesday 4/15
____ Packet Pick-Up on Saturday 4/18
____ Packet Pick-Up on Tuesday 4/21
____ Packet Pick-Up on Wednesday 4/22
T-SHIRT SIZE?
□
S
□
M
□
L
DID YOU SIGN THE WAIVER ON OTHER SIDE OF THIS FORM?
□ XL
□Y □ N
□
2XL
□
3XL
SEND THIS FORM (BOTH SIDES) VIA EMAIL OR FAX TO:
Cynthia Gonzalez - Giving DuPage
[email protected]
Send via Fax (630) 407-6601
Questions? Contact (630) 407-6604
OFFICE USE:
Date Received _________ Date contacted _________ Assignment _____________
WAIVER & RELEASE FROM LIABILITY
USE OF IMAGE/PHOTO RELEASE
All VOLUNTEERS IN THE DUPAGE HUMAN RACE 5K RUN/2MILE WALK AND RELATED EVENTS ("Race")
ARE REQUIRED TO ASSUME ALL RISK OF PARTICIPATION IN THE RACE BY SIGNING THIS RELEASE AND
WAIVER OF LIABILITY AGREEMENT
The undersigned Volunteer ("Volunteer") on behalf of himself/herself and on behalf of the Volunteer~
personal representatives, assigns, heirs, executors, hereby fully and forever releases, waives,
discharges and covenants not to sue the County of DuPage, Giving DuPage, Hamilton Partners and the
Esplanade at Locust Point, USATF, all other volunteers, and all municipal agencies whose property
and/or personnel are used, and all other sponsoring or co-sponsoring companies or Individuals related
to the race (collectively, "Releasees") from all liability to the Volunteer and his/her personal
representatives, assigns, heirs and executors. for all loss(es) or damage(s) and any and all claims or
demands therefore, on account of injury or death to the Volunteer or damage to property, whether
caused by the active or passive negligence of all or any of the Releasees or otherwise, in connection
with the Volunteer's participation in the Race. The Volunteer is fully aware of the risks and hazards
inherent in volunteering in the Race and hereby elects to help with the Race, knowing the risks
associated with the Race, including, without limitation, weather conditions such as bitter cold, high
heat and/or humidity, traffic and the condition of the Race course, all such risks being known and
appreciated by the Volunteer. The Volunteer hereby assumes all risks of loss(es), damage(s), or
Injury(ies) that may be sustained by him/her while volunteering for the Race. The Volunteer agrees to
the use of his/her name and/or photograph in broadcasts, newspapers, brochures, internet and other
media without compensation. The Volunteer hereby grants to the medical director(s) of the Race and
his or her agents, affiliates and designees, access to all medical records (and physicians) as needed and
authorizes medical treatment as needed. The Volunteer warrants that all statements made herein are
true and correct and understands that Releasees have relied on them in allowing the Volunteer to help
with the Race. The Volunteer provides full consent and permission to Giving DuPage, the County of
DuPage, Human Race Sponsors, Race Affiliates, and assigns irrevocable right to use, for any purpose
whatsoever, and without compensation, any photographs, videos, audiotapes and/or other recordings,
of Volunteer, made during course of volunteer activities.
THE VOLUNTEER HAS READ THE FOREGOING AND INTENTIONALLY AND VOLUNTARILY SIGNS THIS
RELEASE AND WAIVER OF LIABILITY AGREEMENT.
___________________________________
Signature of Volunteer
________________________
Date
___________________________________
Printed Name
___________________________________
Signature of Parent or Legal Guardian
(if participant is under 18 years of age)
________________________
Date
**WAIVER MUST BE SIGNED**