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Hearts & Hammers Service Request
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Primary Contact Information
Primary Contact Name
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First
Last
Address where Services are Requested
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Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Hawaii
Idaho
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Iowa
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Texas
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Zip Code
Primary Contact Phone Number
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Primary Contact Email
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Primary Contact Date of Birth
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Number of Individuals in Household
*
Are you a FVUMC Member?
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Yes
No
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Alternate Contact Information
Please provide information for an alternate contact that we may call upon if we are unable to reach you. You may skip this section if you do not have any alternate contact information to provide.
Alternate Contact Name
First
Last
Alternate Contact Phone
Alternate Contact Email
Relationship of Alternate Contact to Requestor
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Service Information
Please provide the following information to help us better understand the services needed.
materials where Significant
Significant information about the Requestor, such as health issues, special needs, etc.
*
Description of Service Requested
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Why do you need help with this project
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Time Frame Requested for Service to be Completed
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Are you able to pay for the materials needed?
*
How did you hear about this ministry?
*
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Requestor Release and Waiver of Liability
Please review and sign this Requestor Release and Waiver of Liability.
Requestor Release and Waiver of Liability Scope of Relationship. I desire to receive services to be performed by volunteers of a ministry of Fuquay-Varina United Methodist Church, Inc. (“FVUMC”). To the extent that such services include the repair, modification, or improvement of real or personal property, I agree that I shall only authorize services to be performed on property that I own or otherwise have a right to repair, modify, or improve. Release from Liability. I hereby agree, on behalf of myself, my heirs and my personal representatives, to fully and forever discharge and release FVUMC, its successors and assigns, its volunteers, and their respective partners, agents, operators, managers, employees, and representatives (“Released Parties”) from any and all claims I may have or hereinafter have for any injury, illness, temporary or permanent disability, death, damages, liabilities, expenses and/or causes of action, now known or hereinafter known in any jurisdiction in the world, attributable or relating in any manner to my receipt of services, whether caused by the negligence of the Released Parties or by any other reason. I acknowledge and agree that this Requestor Release and Waiver of Liability is intended to be, and is, a complete release of any responsibility of the Released Parties for any and all personal injuries, illness, temporary or permanent disability, death, and/or property damage sustained by me as a result of being provided services. No Insurance Required. I understand that FVUMC is not required to provide insurance, nor is FVUMC required to provide any financial or other assistance, in the event of injury, illness, disability, death, or property damage related to my receipt of services. Medical Treatment. I hereby release and forever discharge FVUMC from any claim whatsoever which arises or may hereafter arise on account of any medical treatment or services, including first-aid or similar services, rendered in connection with my receipt of services. Assumption of Risk. I understand and acknowledge that the provision of services by volunteers may be dangerous and may involve risk that property will be damaged or destroyed, or that individuals may suffer serious injury, illness, temporary or permanent disability, or death. I understand that in the event of injury or illness, neither the volunteers nor FVUMC are required to provide medical services, and any injury or illness sustained may be compounded by negligent or delayed medical service. I VOLUNTARILY AND FREELY ASSUME ALL RISKS AND DANGERS THAT MAY OCCUR PURSUANT TO MY RECEIPT OF SERVICES, INCLUDING THE RISK OF INJURY, ILLNESS, TEMPORARY OR PERMANENT DISABILITY, DEATH, OR PROPERTY DAMAGE. Indemnification. I agree to indemnify and hold harmless FVUMC for all claims, accusations, notices, judgments, rulings, liabilities or expenses arising out of my receipt of services. Covenant Not to Sue. I agree, for myself and all my heirs, successors and assigns, not to sue the Released Parties or initiate or assist in the prosecution of any claim for damages or cause of action against the Released Parties which I or my heirs may have as a result of any personal injury, illness, temporary or permanent disability, death or property damage I may sustain as a result of my receipt of services. Publicity Release. I hereby grant to FVUMC all rights, title, and interest in and to any and all photographic images and video or audio recordings made in connection with my receipt of services, including but not limited to any royalties, proceeds or other benefits from such photographs or recordings. I grant permission to FVUMC to make photographs, video, and audio recordings of the area where services are being provided and use them as well as my image in print, video, web, social and/or digital media by FVUMC. Miscellaneous. I understand that this document is a contract which grants certain rights to, and eliminates the liability of, FVUMC and the other Released Parties. This Requestor Release and Waiver of Liability shall be governed by the laws of the State of North Carolina. This Requestor Release and Waiver of Liability is intended to be as broad and inclusive as permitted by law. In the event any provision of this Requestor Release and Waiver of Liability shall be held to be invalid by any court of competent jurisdiction, the invalidity of such provision shall not otherwise affect the remaining provisions of this agreement, which shall continue to be enforceable.
Signature
*
Clear Signature
By signing below, I express my intent to enter into this Requestor Release and Waiver of Liability, and I do so willingly and voluntarily. I understand that by signing this form, I am giving up legal rights and remedies.
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