Email

Occupation (list employer or school)

Areas of special interest or abilities (i.e. Senior Escort: Medical Appointments, crafts, exercise):

Languages

Relationship

Emergency Contact Email

General Health (explain any medical or physical limitation that might impact your work as a volunteer)

List any allergies

Volunteer Declaration, Statement of Confidentiality, Liability Waiver, and Photo/Video Release For Public Relations Materials

I certify that the above information is true and correct to the best of my knowledge. I agree to uphold the professional code of confidentiality. I understand that I am not to discuss any client information outside of the agency unless it is with an agency professional as part of the treatment plan or as part of privileged communication between myself and professional involved in the health and well being of the client. I, the undersigned, or as parent and guardian of the undersigned, hereby waive and release Kimochi, Inc., its employees, agents, officers, personal representatives, successors or predecessors in interest, insurance companies from any and all actions, causes of action, claims, demands, costs, loss of services, expenses and compensation, on account of, or in any way growing out of, any and all known and unknown personal injuries, property damage and intangible damage resulting or to result from or by reason arising out of my work at Kimochi, Inc. and its facilities. I agree that if I am working as a volunteer, I am doing so at my own risk and I agree to hold Kimochi, Inc. and its employees and agents harmless for any harm that I may incur or while doing activities at Kimochi, Inc. I understand that Kimochi, Inc. produces and updates its multi-media public relation materials (newsletters, e-blasts, website, etc.). I give my consent without reservation for any photo(s)/video(s) taken at the Kimochi sites/events of myself included and my name to be part of Kimochi, Inc.’s multi-media public relation materials. I recognize that Kimochi, Inc. will do its best to update public relations materials, however, photo(s)/video(s) of individuals may be used perpetual even after the person(s) has/have passed away. All photo(s)/video(s) taken will become the sole property of Kimochi, Inc. Use of photo(s)/video(s) will require written request by the individual(s) and in turn written approval from Kimochi, Inc. will be required before photo(s)/video(s) are released for the purpose to promote a positive image for Kimochi, Inc.

Kimochi Volunteer Form