Volunteer Application

Basic Information

First Name

Last Name

Name for Name Tag

Email Address

Phone

Date of Birth

Gender

Zip Code

City

State

Skills

Choose any that apply

Fluent in American Sign Language (ASL)

Special Education Teacher

Healthcare professional (please explain in the field provided.)

Current volunteer in Special Needs Organization/Ministry

List professional healthcare field

What are your qualifications, and/or what experience do you have serving the special needs community?

Please try to give a detailed answer.

At least one volunteer meeting prior to the event is required, which will you be able to attend? These meetings will be located at Victory Baptist in Rockmart.

Mandatory Meeting is on 2/22/25 @ 10:00AM or 2:00PM for All Volunteers.

Volunteer Information

I have previously volunteered for Night to Shine

Yes

Volunteer role requested

Pick 3 different volunteer roles in order of preference.

First choiceSecond choiceThird choiceOther choice

You must enter the name of the Team Leader for the team. Leave this field blank if you haven't been asked to enter something here.

Publicity Release

By submitting this form to volunteer for Starry Night at Victory Baptist Church, I do hereby give my consent to Victory Baptist to photograph and/or make video or audio recordings of me without limitation and to use such photographs, video tapes, or audio tapes in my name, likeness and voice and/or any related stories. ("Likeness") in connection with any of the work, programs, projects fundraising or other endeavors of Victory Baptist. In any and all media, including and without limitation, electronic and digital media whether known or unknown at this time, forever worldwide and without restriction, without consideration or compensation of any kind. I release, discharge and hold harmless Victory Baptist and its affiliates including without limitation, its officers, directors, shareholders, employees, agents and contractors ("Release Parties") from any and all claims and demands arising out of or in connection with the use of my "Likeness" including slander, libel, invasion of privacy or publicity, and/or copyright infringement ("Release"). This "Release" applies to me and my heirs legal representatives and assigns and I do hereby and release and hold harmless the "Released Parties" from any claim or demand whatsoever arising out of or connected with such use.

I agree to the Publicity Release terms.

Participant name

Participant signature

By typing in the below field, I am accepting this as my electronic signature of this form.

Date

Emergency Medical Information

I, the undersigned volunteer, or parent/guardian of a volunteer under the age of 18 do hereby authorize Victory Baptist a non-profit charitable corporation or its representatives to consent to any x-ray examination, anesthetic, medical or surgical diagnoses or treatment and hospital care to be rendered under general or special supervision and upon the advice of a physician and/or surgeon licensed under the provisions of the Medical Practice Act, and to consent to any x-ray examination anesthetic, dental, surgical diagnoses or treatment and hospital care to be rendered by a dentist licensed under the provisions of the Dental Practice Act.

Participant signature

By typing in the below field, I am accepting this as my electronic signature of this form.

Date

Emergency Contact Name

Emergency Contact Address

Street Address

City

State/Region

Postal/Zip Code

Country

Emergency Contact Phone

Background Check

Background checks are required for all volunteers. More Information about this will be provided at your chosen volunteer meeting and background checks will be run through our local Sherrif's Department.

I understand that I will have my background checked if I wish to volunteer for Starry Night.