Volunteer Sign Up

Step 1 of 4

Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
I wish to receive the Meridian Health Services Newsletter.*
Is the Volunteer is under age 18?*
Parent of Legal Guardian Email*
Volunteer Type*

Emergency Contact Information
Name*
First Last
Relationship*
Phone*

Volunteer Release of Liability
In return for being allowed to participate in Meridian Health Services, Corp. volunteer activities and all related activities, including any activities incidental to such participation (“Volunteer Activities”), the undersigned Volunteer or Parent/Legal Guardian of Volunteer if Volunteer is under age 18 (hereafter referred to using “I”, “me”, or “my”) releases and agrees not to sue Meridian Health Services, Corp., or its officers, directors, employees, sub-contractors, sponsors, agents and affiliates (“Meridian Health Services”) from all present and future claims that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death arising as a result of my participation in the Volunteer Activities wherever, whenever, or however the same may occur. I understand and agree that Meridian Health Services is not responsible for any injury or property damage arising out of the Volunteer Activities, even if caused by their ordinary negligence or otherwise. I understand that participation in the Volunteer Activities involves certain risks, including, but not limited to, serious injury and death. I am voluntarily participating in the Volunteer Activities with knowledge of the danger involved and I agree to accept all risks of participation. I also agree to indemnify and hold harmless Meridian Health Services for all claims arising out of my participation in the Volunteer Activities. I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state of Indiana and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect. I also acknowledge that Meridian Health Services has not arranged and do not carry any insurance of any kind for my benefit or that of Volunteer (if Volunteer is under 18), my parents, guardians, trustees, heirs, executors, administrators, successors and assigns. I represent that, to my knowledge, I am in good health and suffer no physical impairment that would or should prevent my participation in such Volunteer Activities. I also understand that this document is a contract which grants certain rights to and eliminates the liability of Meridian Health Services.
Digital Signature of Volunteer:*
I am of legal age and am freely signing this agreement. I have read this form and understand that by signing this form, I am giving up legal rights and remedies.
Digital Signature of Parent/Legal Guardian if Volunteer is Under 18:*
I am the parent or legal guardian of the Volunteer. I am of legal age and am freely signing this agreement. I have read this form and understand that by signing this form, I am giving up legal rights and remedies.
Volunteer Release of Liability Signed On:
Date Format: MM slash DD slash YYYY

Input date

Volunteer Publicity Release
In return for being allowed to participate in Meridian Health Services volunteer activities and all related activities, including any activities incidental to such participation (“Volunteer Activities”), the undersigned Volunteer or Parent/Legal Guardian of Volunteer if Volunteer is under age 18 (hereafter referred to using “I”, “me”, or “my”) hereby grants to Meridian Health Services, and each of its subsidiaries, affiliates, agents, advertising or promotional agencies, and partners, and all such entities’ officers, directors, agents, employees, respective successors and assigns (collectively, “Authorized Parties”), the absolute and irrevocable right and permission to use, publish, broadcast and/or copyright the use of Volunteer’s name, address, voice, photograph and/or likeness, caricature, and personal information, in its current form or as retouched, digitized, cropped, altered, distorted or modified in any way, in any and all advertising, promotional, or other materials based upon or derived from the Volunteer Activities in any manner, in any media whatsoever for any and all purposes, including by way of example but without limitation advertising, promoting or publicizing products and services throughout the universe, in perpetuity, in any and all media now known or hereafter devised (including without limitation on the Internet), without additional compensation. I further agree that anything derived there from will be owned solely by the Authorized Parties. I shall not authorize the use of any print, negative or other copy thereof by anyone other than the Authorized Parties. I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the Volunteer Activities take place and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect.
Digital Signature of Volunteer:*
Digital Signature of Parent/Legal Guardian if Volunteer is Under 18:*
Volunteer Publicity Release Signed On:
Date Format: MM slash DD slash YYYY

Input date

Step 1 of 4

Emergency Contact Information

Volunteer Release of Liability

Volunteer Publicity Release

Services

Stay Up to Date

Meridian Matters Podcast: Episode 1

Meridian Dental Health - Dr. David Austin

Physicians “Thank You”

Dr. Maya Profile Spotlight – Pediatrician

Step 1 of 4

Emergency Contact Information

Volunteer Release of Liability

Volunteer Publicity Release

Services

Stay Up to Date

Meridian Matters Podcast: Episode 1

Meridian Dental Health - Dr. David Austin

Physicians “Thank You”

Dr. Maya Profile Spotlight – Pediatrician

Don't Miss Out!