EmailMe Form - Volunteer Information and Acknowledgement of Risk

Full Name

Street Address

Mailing Address if Different

City, State Zip

Phone:

### - ### - ####

Are you 18 years of age or older?

Email

In the event of an emergency, please contact:

Full Name

Relationship

Street Address

City *

State *

Zip *

Phone

### - ### - ####

Volunteers are required to maintain health insurance to cover medical expenses incurred due to any injury or illness that may occur while volunteering for the State Arboretum of Virginia at Blandy Experimental Farm.

Please list any health problems we should know about, e.g. allergies, diabetes, arthritis, asthma, etc.

Physical limitations if any, briefly describe and accommodations needed

Volunteer Profile:

This information helps us find the best possible match for your preference, schedule and skills.

Please list your skills, training, interests, and/or hobbies:

Do you prefer working:

Directly with people

Behind the scenes

No preference

Please check the days you are available? *

Check the boxes to indicate the volunteer opportunities that interest you: *

I have volunteered to work at the State Arboretum of Virginia at Blandy Experimental Farm.

I understand that working at Blandy involves the following risks: exposure to vegetation, poisonous insects, animals, and snakes; exposure to herbicides, insecticides, and other chemicals and allergens; injury from hand tools, power tools, and vehicles operated by volunteers, staff, or members of the public; risks on the premises such as groundhog holes, dead tree limbs, and steep staircases. I understand that these are only a few examples of risks and does not represent a complete list of potential hazards inherent in working in a rural, wooded, outdoor environment.

I acknowledge that those risks exist. I freely accept the potential hazards associated with volunteer work at Blandy. I assert that I am in good health and that I will check with my personal physician if I have any doubt about my fitness for doing outdoor work at Blandy. I acknowledge that I have been informed of my right to decline any task which might exceed my physical abilities or that I prefer not to do. I further agree that I assume full responsibility for any injuries I may incur while performing volunteer activities, unless an injury occurs due to the total negligence of Blandy or its employees and agents.

I also agree that I will not use any tool, vehicle, or piece of equipment unless I am fully familiar with its operation and have been properly trained in its use by the staff of the Blandy Experimental Farm.

As an authorized volunteer, I understand that I will be acting on behalf of the University of Virginia and I will conduct my activities accordingly. I have read and agree to the terms and conditions of my volunteer activities outlined in this form and further understand that for my personal safety I must follow the directions of the faculty or staff member supervising my activities. I also hereby agree that in my capacity of a volunteer, I am not covered by University or Commonwealth insurance programs such as employee health insurance or workers’ compensation. Additionally, I acknowledge that the university may deem it necessary to conduct a criminal background check on me in my capacity as a volunteer. I understand that I volunteer my services at the will and pleasure of the staff and management of the University of Virginia and that my services may be terminated at any time, for any reason, at the sole discretion of the University.

Agree to terms above:

I have read and agree to these terms.

A copy of this form will be emailed to you at the above address.

You will be notified of acceptance pending review of your submitted information by the Volunteer Coordinator and the Director of Blandy Experimental Farm.

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