First Name *

Last Name *

Email *

Phone *

Address

City

State

Postal code

Volunteering as a Group? Please elaborate

Have you ever done any volunteer work?

Yes

If yes, please summarize Volunteer Work below

Availability

Hours Available to Volunteer

9am - 11am

11am - 1pm

1pm - 3pm

3pm - 5pm

Emergency Contact Info

Emergency Contact

Emergency Contact - Phone

Emergency Contact - Address

Image, Video & Story Release

Release of Image, Video, Story Terms

I grant permission to Harford Community Action Agency to use my story, video, and/or images provided by me or taken of me during a HCAA gathering. Without further notification, the materials may be used for publications.

This release includes the use in both internal and external publications, such as: website feature articles, social media posts, donor letters, grant applications, and general publicity.

I release Harford Community Action Agency and its employees from any claims, damages, or liability.

I am at least 18 years of age* and competent to sign this release. I have read this release before signing and I understand this agreement and accept the terms.

I understand that this document will be submitted electronically. By inserting my name I agree to the terms and conditions.

Prefer Non-Contact Volunteer Opportunities?

Prepare Toiletry Kits

Prepare toiletry kits for mobile pantry in quart sized ziplock bags(trial-size toothpaste, soap, hand sanitizer, mouthwash, chap stick and tooth brush).

I am planning to put together Toiletry Kits for the Mobile Pantry

Yes

Hold a Food Drive!

Plan, coordinate and facilitate a food drive with items for the mobile pantry with a focus on individual servings of items (microwaveable mac and cheese cups, pasta/sauce cups, granola bars, cereal bars, chips, cookies, crackers, fruit bites, juice pouches, canned tuna and chicken, apple sauce and fruit cups/pouches).

I am planning to hold a Food Drive

Yes

Hold a Fundraiser!

Plan coordinate, and facilitate fundraisers to raise monetary funds for HCAA programs

I am planning to hold a Fundraiser

Yes

Under 18?

If you are under 18, please have a parent or guardian complete the following:

Parent's Name

Parent's Email

Confidentiality Agreement

It is the policy of Harford Community Action Agency, Inc. to safeguard private information provided by persons who apply for or participate in assistance programs administered by this agency. Private information is any information obtained about a person that might identify him/her as an applicant for assistance or a program participant. Private information to which the employee/volunteer of this agency has access to shall not be used, published or disclosed in any form, to any person, corporation, agency (governmentt or otherwise) except as required in fulfilling obligations in administering a program. The employee/volunteer agrees to maintain the strict privacy of information and to follow the agency’s employees/volunteers who require it to conduct their job activities. If the employee/volunteer is subpoenaed or otherwise believes that he/she may be called upon to make a disclosure of private information to any court or governmental agency, he/she shall immediately notify the agency’s director. At the director’s request, the employee/volunteer shall cooperate in all lawful efforts to protect private information. The failure of the employee/volunteer to comply with the above confidentiality requirements is grounds for dismissal. The restriction of the Agreement regarding use and disclosure of private information shall continue to apply after termination of the employee/volunteer. The employee/volunteer has read and understands the above statement and agrees to comply with it in every respect.

Captcha