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The Arc of Fort Bend County Advocacy and Services for People with Special Needs

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For people with intellectual and development disabilites.

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Respite Volunteer Application

Click here to download PDF Application

If you have any questions, you may contact Karri Axtell at info@arcoffortbend.org or 281-494-5924.

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Volunteer Information
Respite Dates 2018 (Friday 5:30-9:30PM)
Select Available Dates*
- 2/1/2019
- 3/1/2019
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Sex*
DOB & Age*
Primary Language*
Are you a minor? (Under age 18)*
- Yes
- No
Adult volunteers: Will you consent to a criminal history background check?*
- Yes
- No
Driver License or State ID Number*
Minor Volunteer Information
Parent/Guardian Name*
Relationship*
- Mother
- Father
- Legal Guardian
Parent/Guardian Phone*
Parent/Guardian Email*

Emergency Contact Information
Emergency Contact Name
First Last
Relationship to Contact
Emergency Contact Phone

Background Information - Volunteer Experience
Dates
Organization (Camp, Church, etc.)
Position or Service Project
List any other volunteer experience (Date - Organization - Position or project)
Describe a time in which you served another individual as a volunteer
Do you have any prior experience working with individuals with intellectual or developmental disabilities?*
Please check all attributes that you would feel comfortable working with:*
- OK with any disability
- Non-verbal
- Down Syndrome
- Intellectual disability
- Male
- Female
- Severe disability
- Age 11-14
- OK with any level of assistance needed
- Needs assistance with eating
- Needs assistance with toileting
- Needs assistance with fine motor tasks

References
1. Name*
Relationship*
Phone*
2. Name*
Relationship*
Phone*

The Arc of Fort Bend County and Texana Center Activities Release and Waiver of Liability
This program is not licensed by the State of Texas. By signing below you agree to accept the terms.

This activities release and waiver of liability is being executed in favor of The Arc of Fort Bend County, The Arc of Texas, The Arc National, Texana Center and/or any affiliated entities, their Directors, Officers, Employees, volunteers and agents (together, “The Arc and Texana”), for the activities described below. I freely and voluntarily execute this activities release and waiver of liability, and agree to the following terms:
GENERAL RELEASE AND WAIVER*
- I, the undersigned, understand that occasionally accidents occur during activities and participants may sustain serious personal injury and property damage as a consequence thereof. Nonetheless, knowing the risks of activities, I agree to assume the risks. By signing this activities release and waiver of liability, I intend to legally bind myself, my minor children, my heirs, executors and administrators. I hereby release and forever discharge and hold harmless The Arc and Texana, and its successors and assigns from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, which arise at any time from the activities with The Arc and Texana.
INDEMNIFICATION*
- The Undersigned shall indemnify, defend, and hold harmless The Arc and Texana, its Directors, Officers, Employees and Agents, and its successors and assigns from any and all liability, claims, costs and losses, whether related to property damage, personal injury or death, arising from the Undersigned’s participation in activities, whether caused by the willful or negligent acts of Undersigned or the negligent acts of The Arc, Texana, or its Directors, Officers, Employees, Clients, Volunteers or Agents. This provision shall survive the term of this agreement.
VOLUNTEER CONSENT*
- I understand and certify that my participation in The Arc and Texana Teen-Tween Respite is completely voluntary. I have familiarized myself with the program and activities in which I will be participating. I acknowledge that although safety measures and reasonable care to minimize the risk of injury are taken, The Arc and Texana cannot ensure or guarantee that the volunteers, equipment, premises or activities will be free of hazards, accidents or injuries. I have received approval from a doctor authorizing me to participate in the activities. I understand this program is NOT licensed by the state of Texas.
INSURANCE*
- The undersigned understands that The Arc and Texana do not carry or maintain health, medical or disability insurance coverage for any undersigned. The Undersigned is expected, and encouraged to, obtain his or her own medical or health insurance coverage. I also understand that The Arc and Texana do not assume any responsibility for, or obligation to provide, any financial assistance or other assistance, including, but not limited to medical, health, or disability insurance in the event of injury or illness.
MEDICAL TREATMENT*
- If emergency treatment is necessary, I give permission to be taken to the nearest hospital for treatment, by ambulance. I understand treatment is not covered by The Arc or Texana. The undersigned releases and forever discharges The Arc and Texana from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with activities of The Arc and Texana.
VOLUNTEER EXPECTATIONS*
- I agree to conform to the program rules and expectations of all volunteers. I agree to arrive at the assigned time to receive training and instructions regarding the event, my assigned duties, and/or the participant I have been matched with. If I am not performing in accordance with the program rules and expectations, I understand I may be asked to leave, and /or not allowed to return as a volunteer for future activities.
CONFIDENTIALITY*
- The undersigned understands that information regarding the Teen-Tween Respite participants and their personal, financial, disability, health, medical and other related information is confidential. I agree to keep all such information confidential. I understand that unauthorized disclosure of such information is grounds for immediate termination as a volunteer, and may result in additional legal action taken against me
VOLUNTEER BACKGROUND CHECK*
- I consent to The Arc performing a background check to gather information relating to any criminal history and/or sex offender history through SureHire 360.
MEDIA RELEASE*
- The undersigned agrees to the digital, print or other medium use of their likeliness, and waives all rights and interests in such materials.
ADDITIONAL TERMS*
- The undersigned expressly agrees that the activities release and waiver of liability are intended to be as broad and inclusive as permitted by the laws of the State of Texas. This agreement shall be governed and interpreted in accordance with the laws of the State of Texas, U..S.A. I agree if any provision of this agreement shall be declared by any court of competent jurisdiction to be illegal, void, or unenforceable, the other provisions shall not be affected but shall remain in full force and effect. This agreement shall be binding on and inure to the benefit of the parties hereto and their respective heirs, legal or personal representatives, successors, and assigns.
Volunteer Name*
Date*
Signature*

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