Title Prefix Icon Heal Elgin Volunteer Registration

Must be legal and current information for insurance purposes
Legal First name
Legal Middle Name
Legal Last Name

Title Prefix Icon Demographic Information

Volunteer demographics is mostly optional and assists in obtaining grants for the project
Title Prefix Icon Volunteers must be 14+ years old by clinic date. Minors must have a signed release form on file and be accompanied by a parent/guardian at all times during the clinic.
because there is food service and we are working in a patient environment, please list any and all allergies
This data is used to establish funding grants for the Heal Elgin Project
This data is used to establish funding grants for the Heal Elgin Project
This data is used to establish funding grants for the Heal Elgin Project
Select all languages you speak fluently.
Required for all volunteers to receive and wear the Heal Elgin T-shirt

Title Prefix Icon Emergency Contact Information

This information is required for insurance purposes
Required for insurance purposes

Title Prefix Icon Skilled & Registered Professionals

Details are required here by State Law and insurance purposes
Identify with the designations you are licensed in
Identify with the designations you are licensed in
Identify with the designations you are licensed in
Identify with the course of study desgination
Select the US State or Location in which you are licensed.
List where you are licensed (state, country, province)
Upload a copy of your license. For those wishing to practice within your licensed profession, your application will not be complete without a valid license on file.
No Choosen File
(Max 10 MB)

Title Prefix Icon General Volunteer Details

Select the dates you want to volunteer for. Friday is setup
Select the interest area. Professional roles require a valid license or are currently a student in those professions.
Those seeking CE/CME must bring the associate forms with you and advise at checkin.
Volunteer Release and Waiver of Liability Please read carefully. Upon submission, this is a legal acknowledgement of the following: This Release and Waiver of Liability (the “release”) executed on ______________ (date) by _________________________________________ (“Volunteer”) releases Love Heals Free Clinics (“Nonprofit”), a nonprofit corporation organized and existing under the laws of the State of Idaho and each of its directors, officers, employees, and agents. The Volunteer desires to provide and engage in activities related to serving as a volunteer. Volunteer understands that the scope of Volunteer’s relationship with Love Heals Free Clinics is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; that Love Heals Free Clinics will not provide any benefits traditionally associated with employment to Volunteer; and that the Volunteer is responsible for his/her own insurance coverage in the event of personal injury or illness are a result of Volunteer’s services to Love Heals Free Clinics. 1. Waiver and Release: I, the Volunteer, release and forever discharge and hold harmless Love Heals Free Clinics and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services I provide to Love Heals Free Clinics. I understand and acknowledge that this Release discharges Love Heals Free Clinics from any liability or claim that I may have against Love Heals Free Clinics with respect to bodily injury, personal injury, illness, death, or property damage that may results from the services I provide to Love Heals Free Clinics or occuring while I am providing volunteer services. 2. Insurance: Further, I understand that Love Heals Free Clinics does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability on the part of Love Heals Free Clinics beyond what may be offered freely by Love Heals Free Clinics in the event of injury or medical expenses incurred by me. 3. Medical Treatment: I hereby Release and forever discharge Love Heals Free Clinics from any claim whatsoever, which arises or may hereafter arise, on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with Love Heals Free Clinics. 4481 N Dresden Place Garden City, Idaho 83714 208-918-0588 www.LoveHealsFreeClinic.org 4. Assumption of Risk: I understand that my participation as a volunteer may expose me to risks of bodily injury, personal injury, illness, death, or property damage. Further, I acknowledge that I may be exposed to risks that are not foreseeable. As a volunteer, I hereby expressly assume risk of injury or harm from these activities and Release Love Heals Free Clinics from all liability. 5. Photographic Release: I grant and convey to Love Heals Free Clinics all right, title, and interests in any and all photographs, images, video, or audio recordings of me containing my likeness or voice made by Love Heals Free Clinics in connection with my providing volunteer services to Love Heals Free Clinics. 6. Other: As a volunteer, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws in the State of Idaho and that this Release shall be governed by and interpreted in accordance with the laws of the State of Idaho. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provision of this Release shall not be affected.