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Project United Waiver

Participant Information

Name

Company

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Emergency Contact

Name

Phone

Demographic Information

The United Way of Western Kentucky uses demographic information for the sole purpose of evaluating it's efforts towards diversity, equity and inclusion in our local community.

If you choose to participate, please select how you describe yourself. You may choose multiple options.

Gender Identity

Male

Female

Another Identity

Racial and Ethnic Identity

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino or Spanish Origin

Middle Eastern or North African

Multiethnic

Native Hawaiian or Pacific Islander

White

Another Identity

Consent and Release Agreement

By checking this box, I hereby grant the United Way of Western Kentucky (UWWKY) permission to interview me and use my comments or likeness in photographs or video for any and all lawful purposes that support the creation, marketing, or distribution of any pieces of video production connected to UWWKY engagement efforts for broadcast or private use. I understand that use of my interview or likeness does not entitle me to compensation in any form, and I will make no monetary claim against UWWKY for the interviews, photographs, or videos regardless of how, when or whether such interview or likeness is used. Although my personal use is permitted, I understand that my interview or likeness in photographs or videos will become the sole property of UWWKY.

By checking this box, I request to be considered as a volunteer for UWWKY. In consideration of being allowed to serve in a volunteer position (the “Activity”), I acknowledge, understand, and agree that: 1. I am strictly a volunteer, not an employee of UWWKY, and I understand that I will receive no monetary compensation or benefits from my service as a volunteer. 2. Workers’ compensation insurance does not cover my volunteer position with UWWKY, and it is my responsibility to provide my own medical insurance. 3. My presence at and/or participation in the Activity is voluntary in nature, and I am free to leave at any time. I, for myself and on behalf of my heirs, assigns, personal representatives, family and next of kin, HEREBY WAIVE ANY CLAIMS AGAINST, RELEASE, HOLD HARMLESS, AND PROMISE NOT TO SUE UWWKY and its officers, directors, officials, agents, volunteers, employees, or its agencies, sponsors (hereinafter collectively referred to as the “Releasees”), WITH RESPECT TO THE ACTIVITY AND ANY AND ALL INJURY or loss or damage to my person or property, WHETHER ARISING FROM, OR CAUSED BY, THE NEGLIGENCE OR GROSS NEGLIGENCE OF THE RELEASEES OR OTHERWISE, except that which is the result of wanton or intentional misconduct of the particular Releasee(s).

I am 18 years of age or older. I have read this release. I understand the information contained in this release, and I am competent to provide this authorization.

Yes

I am under 18 years of age. I have had a parent, guardian or caregiver read this release who understands the information contained in this release. That person is competent to provide this authorization on my behalf.

Yes

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