Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Do you have construction experience? If so, what kind? *

Yes

No

Any dietary restrictions? *

Yes

No

Do you give us permission to use photos of you for promotional purposes? *

Yes

No

Emergency Contact Phone

(###)

###

####

Do you want Circle to purchase Emergency Medical Insurance for you for $30?

If you check yes, please add $30 to your trip cost (Total trip cost = $155). See plan at volunteercard.com

Accept

Decline

Liability Agreement *

I hereby remise, release and forever discharge Circle of Concern, its employees, agents, servants and all other persons, firms and corporations whomsoever of and from any and all actions, claims and demands, whosoever which claimant now has or may hereafter have on account of or arising out of any accident, casualty and/or action which might happen while participating in programs/events. I further understand that there is no Worker’s Compensation or Accident Insurance furnished by Circle of Concern for such programs/events. I acknowledge that I am responsible for any and all personal medical expenses while participating in all programs/events, and agree to hold harmless Circle of Concern of any and all liability that may arise out of such participation.

Agree

Disagree

Family Member 2

First Name

Last Name

Check box only if under 18 years old

Under 18 years old

Family Member 3

First Name

Last Name

Check box only if under 18 years old

Under 18 years old

Family Member 4

First Name

Last Name

Check box only if under 18 years old

Under 18 years old