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2. Nonstatutory Volunteer Coverage Application
4. Entity name:*
   -- Select One --City of Pleasant Hill
6. Volunteer name*
7. Driver's license #*
9. City*
10. State*
11. Zip*
13. Email*
14. Phone Number*
16. Volunteer assignment*

    If unknown type 'TBD'

18. Date assigned*
    Date assigned

    Date assigned

    If unknown type current date

20. Supervisor should review the following with each volunteer:*

    1. Safety rules and enforcement procedure
    2. Proper use of tools and equipment
    3. Proper work shoes and other personal protective equipment
    4. Special hazards of assignment
    5. Department emergency procedures

    Please check all boxes

22. Additional comments/notes
24. I certify that I have reviewed all of the above safety policies and procedures with the department supervisor and acknowledge receipt of a copy of this application.*

    Type volunteer name

26. Release and waiver of liability

    The undersigned acknowledges and agrees as follows

    A. The undersigned has offered to provide certain work or services to the Member and the status of the undersigned while performing such work or services is that of a nonstatutory volunteer (hereinafter “volunteer").

    B. The volunteer is not considered an employee of the Member and is not entitled to any benefits under the Iowa Compensation Law for injury incurred while providing work or services regardless of the cause of the injury.

    C. The Member has purchased a limited amount of excess coverage insurance to cover any medical expenses Incurred by the volunteer as a result of Injury Incurred while the volunteer is providing such work or services, and the payment of these medical expenses is to be made In accordance with the terms of the Description of Benefits set out In this application.

    D. The volunteer specifically waives the right to any other benefits, reimbursements or damages as a result of injuries which the volunteer may incur while providing such work or services.

    E. The volunteer specifically releases, waives and covenants not to sue the Member and or IMWCA for injury or death caused by the negligence of other volunteers or of officers, agent representatives or employees of the Member which may occur while the volunteer Is I performing such work or services for the Member.

28. The undersigned has read and voluntarily signs the release and waiver of liability and further agrees that no oral representations, statements or inducements apart from the foregoing written agreement have been made.*

    By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

30. 
31. Let's Talk Parks
    Pleasant Hill Parks

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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field