Volunteer Application Volunteer "*" indicates required fields Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Phone*Alt PhoneDate of Birth* MM slash DD slash YYYY I would like to receive additional communications from Langton Green* Yes, Please! No Thank You, Direct Communications Only I will submit to a background check if necessary* Yes No I grant permission to be photographed for possible inclusion in a Langton Green Community Farm publication or other publications for promoting Langton Green Community Farm.* Yes No Yes, with stipulations I UNDERSTAND THE NATURE OF THE PROGRAM FOR WHICH I WISH TO VOLUNTEER AND CERTIFY THAT THE STATEMENTS ABOVE ARE TRUE AND CORRECT. I UNDERSTAND THAT THE FIRST 10 HOURS OF MY VOLUNTEER SERVICE WILL BE ON A TRIAL BASIS.SignatureDate MM slash DD slash YYYY Medical Release* I agreeIn the event that an emergency arises while volunteering at the Langton Green Community Farm requiring medical treatment, I authorize Langton Green, Inc. to select and designate nurses, physicians, and/or surgeons to furnish medical and/or surgical care, and I authorize such medical and/or surgical care, as in the judgment of a physician and/or surgeon holding a physician’s surgeon certificate issued by the Board of Medical Examiners of the State of Maryland, as may be needed and proper. I absolve the Langton Green Community Farm, nurses, physicians, and/or surgeons selected and designated by any of them, from any and all liability for their acts rendered in good faith.SignatureDate MM slash DD slash YYYY Informed Consent* I agreeI recognize and understand that the activities of my volunteer project(s) at Langton Green, Inc. may be hazardous. I hereby expressly and specifically assume responsibility for any injury or harm resulting from these activities and release and discharge Langton Green, Inc. and representatives thereof from any and all liability for property damage, injury, illness, or death resulting from any volunteer activity.SignatureDate MM slash DD slash YYYY Policies & Procedures I agree to the policy.I have read and understand the policies and procedures of the Langton Green Community Farm.SignatureDate MM slash DD slash YYYY Emergency ContactName* First Last Phone*Relationship* 72457 Have more questions?Contact us at farminfo@langtongreen.org, or download our CSA Member Handbook. CSA Member Handbook
