Speakers Bureau Volunteer Application
Please provide information requested below after each colon.
Basic contact information
Last name:
First name:
Middle Initial:
Address:
City:
County:
State:
Zip:
Home Phone:
Work Phone:
Emergency Phone:
Email:
Preferred Method of Contact? Write yes or no.
Phone:
Email:
Emergency Contact Information
Physician Name:
Physician Phone:
Emergency Contact Person 1:
Emergency Contact Person 1 Phone:
Emergency Contact Person 2:
Emergency Contact Person 2 Phone:
Do you have health insurance? Write yes or no:
I have read, understand and agree to the terms of the Speakers Bureau Volunteer Application listed on
the following page and physically sign this agreement of my own free will.
Physical signature of applicant:
Date:
If applicant is under 18 years of age,
Parent name:
Parent Signature:
Date:
For GDB Office Staff Only:
Name of GDB staff person who will manage this volunteer:_____________________________________________________________
Signature ___approving ___declining application________________________________________________________________
SPEAKERS BUREAU VOLUNTEER TERMS
General Application Terms:
I certify that my answers are true and complete to the best of my knowledge. I agree to complete all the conditions
related to my position as defined by Guide Dogs. I hereby release GDB, employers and other persons from all
liability in responding to inquiries in connection with my application. If I am retained as a volunteer, I realize that
false or misleading information given in my application or interview(s) may result in discharge. I also recognize that
my application can be denied without cause, and that if I am retained, I can be released at the will of the
organization.
I give Guide Dogs for the Blind, Inc. the right and permission to use photos, videos or audio files of me or my child
for publicity purposes or to otherwise promote Guide Dogs for the Blind, Inc. to the public in any manner that Guide
Dogs wishes from the date signed and in perpetuity.
Dogs accompanying Guide Dog for the Blind volunteers to speaking engagements, presentations, demonstrations,
or other such events must be well-mannered, properly handled, healthy, in good condition, and otherwise safe.
Guide Dogs for the Blind (GDB) does not assume the responsibility of screening dogs that accompany volunteers
to these functions. The volunteer is responsible for ensuring that the dog meets safe and reasonable standards and
for being personally liable for the dog's behavior and/or any damages that may occur to people or property. This
condition applies if the dog is personally owned by the volunteer or another person (example: career change dog,
retired guide, retired breeder, K9 Buddy dog, etc.) or is owned by GDB (example: guide, puppy, breeder, etc).
Consent and Release Terms:
I hereby waive and forever discharge claims for damages suffered in connection with Guide Dogs for the Blind, Inc.
sponsored events that the above listed individual, their heirs, executors and administrators may have or accrue
against Guide Dogs for the Blind, Inc., its representatives, agents and volunteers. I also understand that I will be
responsible for any costs of any service or treatment provided not covered by insurance of Guide Dogs for the
Blind, Inc.
I agree to carry my health insurance card with me while volunteering with Guide Dogs for the Blind. In case of
emergency, I understand that every effort will be made to contact the emergency contacted I have indicated. In the
event that they cannot be reached, I hereby give permission to a physician selected by a representative of Guide
Dogs for the Blind, Inc. to hospitalize and secure proper treatment (including surgery).
Terms of Service
I agree to abide by all instructions, guidelines, policies and procedures presented to me by Guide Dogs staff,
supervisory volunteers, written documents and other means. I acknowledge and agree that I will receive no
financial compensation for any services that I may perform for Guide Dogs for the Blind, Inc.
In the course of my assigned Guide Dogs for the Blind duties, as an enrolled volunteer of Guide Dogs for the Blind I
am protected against personal liabilities by GDB general liability insurance and by the Volunteer Protection Act of
1997. Only volunteers who are screened and registered as approved GDB volunteer drivers may drive as an
approved task as a GDB volunteer. All other volunteers who drive are doing so as a personal responsibility without
GDB authorization or liability coverage.
I acknowledge and agree that I may be released from my volunteer duties at any time at the will of Guide Dogs for
the Blind.
Please return completed application to
Guide Dogs for the Blind
Attention: Sierra Fish
PO Box 151200
San Rafael, CA 94915
Fax: 415-472-0128
communityvol@guidedogs.com
For questions, please contact Sierra Fish at 415-499-4058 or sfish@guidedogs.com