Sign-In Sheet & Health Form printable pdf download

(For office use only)

Type of Event: ________________________

Event Name: __________________________

Vol. Hours/Participant: ______

Interest Area (i.e. Oysters, Restoration):

Chesapeake Bay Foundation

________________________________

EPR Volunteer

Sign-In Sheet & Health Form

(Please PRINT)

Event: ___________________________________ Date of event: _____________

Name: _____________________________________________ Date of birth: _____ Sex: M

Address (street address, city, state, zip code):

___________________________________________________________________________

Phone (best phone # to reach the day of the event):___________________________

Participating Spouse’s name: _______________________________ Date of birth: ______ Sex: M

Family or other participants

Name: ___________________ Date of birth: ____

Name: ___________________ Date of birth: ____ Name: _____________________ Date of birth: ____

Email:

In case of emergency, notify:

Name: ___________________________________________________________

Phone (best reached at):_____________________________________

Address (City, State, Zip):_______________________________________________________________

( Check here if same address as above)

Health concerns:

Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes,

allergy to bee stings, etc: ___________________________________________

Where did you hear about this event?

 CBF email CBF mailing CBF website/calendar A friend/family member

Newspaper (name)_____________________ Other

All CBF event participants please read and sign the following:

All of the above information is to the best of my knowledge, correct. I understand that participation in the Chesapeake Bay

Foundation (CBF) activities is entirely voluntary. I understand that the CBF event may involve “hands on” activities such as

planting trees, using equipment, or wading in shallow water; and I understand the risks and dangers involved in the above-

named activities. I know and understand that unanticipated dangers might arise. I hereby release CBF from any responsibility for

injury which might occur as a result of participation in CBF activities. I give permission to authorize personnel to carry out such

emergency diagnostic and therapeutic procedures as may be necessary for me/my child, and also permit such treatment

procedures to be carried out at and by the local hospital(s) for me/ my child in the event of an emergency. I understand that any

medical expenses will be billed directly to me or my insurance company. I hereby grant the Chesapeake Bay Foundation the

unconditional right to use my /my child’s name, voice, and photographic likeness of me /my child in connection with

any of their audio video production, articles, website materials or press releases, but not as an endorsement. If not,



check here

By filling out the information above, I confirm I want to continue to help protect and restore the Chesapeake Bay.

Please sign me up to receive Bay updates from the Chesapeake Bay Foundation.



Check this box to opt out of receiving Bay updates via email.

For children under 18: I give permission for ____________________________ to participate in all field activities,

except as otherwise noted.

_____________________________________

_______________

Signature of participant or parent/guardian

Date

Sign-In Sheet & Health Form

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