Food Security

Your Name

Date of Birth

Your Email

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Branch

I verify that I meet all the required criteria listed with this volunteer opportunity and can provide proof as needed.

Emergency Contact 1 First Name

Last

Emergency Contact 1

Emergency Contact 2 First Name

Last

Emergency Contact 2

Emergency Food Shopping and Delivery

I Verify That

I verify that I have been free from any symptoms indicative of COVID-19 for at least 14 days.

I verify that I am free from medical conditions that would make me vulnerable to COVID-19.

I verify that I have not been in contact with anyone who has exhibited symptoms indicative of COVID-19 in the past 14 days.

I give permission to be photographed, interviewed, quoted, and/or receive recognition for my work and involvement while participating in the YMCA Volunteer Program.

I hereby accept any and all responsibility for, and assume the risk of any and all injury or damage to my person that might arise directly or indirectly as a result of, and or participation as a volunteer for the YMCA of Greater Pittsburgh. I hereby expressly release, discharge and hold harmless from any liability whatsoever the YMCA of Greater Pittsburgh, the various branches and subdivisions thereof, and all employees and volunteers in their capacities as representatives of the YMCA of Greater Pittsburgh.

I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statutes or of offenses similar in nature to those crimes under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.

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