United Way of Broward County ePledge Portal

* First Name:

* Last Name:

* Personal email address:

* Cell phone number:

May receive text message updates

* Address:

* City:

* State:

* Postal/ZIP Code:

* Are you 18 years of age or older?

Yes

No

* Date of birth:

* Volunteer t-shirt sizing information:

* Do you have a Commercial Driver's License?

Yes

No

* Background Clearance?

Level 1

Level 2

None

Are you willing to undergo a background check in the event of a disaster?

Yes

No

* Medical Training/Medical Professional?

Yes

No

* Are you able to lift 50+ pounds?

Yes

No

* Do you have experience operating a chainsaw?

Yes

No

* Do you own a pickup truck?

Yes

No

* Do you own a ladder?

Yes

No

8ft. ladder

Extension ladder

* Can you operate a forklift/pallet jack?

Yes

No

Languages you speak:

* English

Yes

No

* Spanish

Yes

No

* Portuguese

Yes

No

* Creole

Yes

No

* Other

Yes

No

Other languages:

Are you available to volunteer in:

* Broward County?

Yes

No

* Miami-Dade County?

Yes

No

* Palm Beach County?

Yes

No

* Wherever needed?

Yes

No

Have you participated in the following trainings?

* Shelter Fundamentals

Yes

No

* Disaster Mental Health

Yes

No

* Mental Health First Aid Training

Yes

No

* Blue Sky

Yes

No

* CPR

Yes

No

* Caseworker

Yes

No

* CERT

Yes

No

* Other

Yes

No

Other

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Relationship to Self:

Comments

0 of 250 words

I HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS United Way of Broward County, ITS AFFILIATES, AND THEIR DIRECTORS, OFFICERS, SUCCESSORS AND DESIGNS, AND THE ORGANIZERS, SPONSORS AND SUPERVISORS OF ALL ACTIVITIES (PARTIES), FROM ANY AND ALL CLAIMS, LOSSES, DAMAGES, OR LIABILITY IN CONNECTION WITH ANY INJURY OR CLAIM OF DAMAGES INCLUDING ATTORNEY FEES. I UNDERSTAND AND ACKNOWLEDGE THAT THIS RELEASE DISCHARGES PARTIES FROM ANY LIABILITY OR CLAIM I MAY HAVE WITH RESPECT TO BODILY INJURY, PERSONAL INJURY OR PROPERTY DAMAGES THAT MAY OCCUR WHILE I AM PROVIDING VOLUNTEER SERVICES IN CONNECTION WITH United Way of Broward County.

FURTHERMORE, I UNDERSTAND THAT PARTIES DO NOT ASSUME ANY RESPONSIBILITIES OR OBLIGATION TO PROVIDE ME WITH FINANCIAL ASSISTANCE, INCLUDING BUT NOT LIMITED TO MEDICAL, HEALTH OR DISABILITY BENEFITS IN THE EVENT OF ANY INJURY, ILLNESS OR DAMAGE TO MY PROPERTY. AS A VOLUNTEER, I EXPRESSLY AGREE THAT THIS RELEASE IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE STATE OF FLORIDA. AND I AGREE THAT IN THE EVENT THAT ANY CLAUSE OF THIS RELEASE IS DEEMED INVALID, THE ENFORCEABILITY OF THE REMAINING PROVISIONS OF THIS RELEASE SHALL NOT BE AFFECTED. I GRANT AND CONVEY TO UNITED WAY ALL RIGHT AND INTEREST OF ALL PHOTOGRAPH, IMAGES, VIDEO OR AUDIO RECORDINGS OF ME OR MY LIKENESS MADE BY UNITED WAY IN CONNECTION WITH MY PROVIDING VOLUNTEER SERVICES TO UNITED WAY.

* I have read and agree to the above information: