Fillable Canton Community Youth Volunteer Application Form (Please print) (Canton Township)

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Canton Community Youth Volunteer Application Form (Please print) (Canton Township)

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Canton Community Youth Volunteer
Application Form (Please print)
Please return this form to:
Canton Leisure Services
1150 S. Canton Center Rd.
Canton, MI 48188-1699
Phone: 734/394-5191
Fax: 734/394-5319
Name: Birthday: /
First Last Month / Day
Phone: ( ) ( ) ( )
Home Work Cell
Address:
Number Street City Zip
E-Mail Address:
What is your reason for volunteering?
From Canton Leisure Services website list what volunteer opportunities you are
interested in:
Waiver for Volunteers
I hereby agree to indemnify and hold harmless the Township, its elected and appointed officials,
employees, and agents, from any and all risks, claims, demands, damages and other liabilities
arising from my participation as a volunteer, including all costs, expenses and attorney fees paid or
incurred, by reason of personal injury, including bodily injury or death and/or property damage,
including loss of the use thereof, which arises out of, or is in any way connected or associated with
my activity as a volunteer for the Charter Township of Canton.
By checking “yes”, I certify that the information contained in this form is accurate. I Agree: Yes No
I understand that checking this box constitutes a legal signature confirming that I acknowledge that I am the
signer, and further that I agree to the above Terms of acceptance: Yes No
___________________________________
Participant’s signature or Parent/Guardian’s
signature, if participant is under the age of 18
___________________
Date
For Administrative Use Only
Revised: 3/8/2019
□ Background Check Rcd: □ Driving Record Check Rcd:
Visit Canton Leisure Services website at www.cantonfun.org for volunteer opportunities.
Canton Township Leisure Services Department
Volunteer Emergency Medical Information Sheet
Name_______________________________________________Date of Birth________________________
Address______________________________________________________________________
City____________________________________ Zip__________________________________
Phone Number___________________________Other Phone Number_____________________
In case
of emergency, notify______________________________________________________
Relation to Employee ___________________________________________________________
Phone Number__________________________Other Phone Number______________________
2nd Emergency Contact _________________________________________________________
Relation to Employee___________________________ Phone Number __________________
The information below is designed to provide you with proper medical care in the event of an emergency
and is VOLUNTARY- completion of the below is OPTIONAL:
Allergies/sensitivities:_________________________________________________________________
Medical conditions the Township should be aware of:________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Medications:___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
The information I have provided above is accurate. I understand and acknowledge that this information
could be made available to any employee who could assist me in the event of an emergency.
______________________
Date
______________________
_________________________________________
Volunteer's Signature
_________________________________________
Parent/Guardian of Volunteer (if minor)
Date
Revised 5/10/2017
In
ternal Use Only
___ Original sent to CLS Administration Office ___ Copy sent to volunteer's work site
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Canton Community Youth Volunteer Application Form (Please print) (Canton Township)

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Completed 31 January 2021

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