Volunteer Application
Thank you for choosing to become a GEMS Volunteer! We greatly appreciate you
giving us the gift of your time and talents to help us serve the COMMUNITY! Please
print or complete the application online to let us know which volunteer areas you are most interested, save and send
the form to us: 1) via email at [email protected] or 2) by U.S. Mail: GEMS Inc., 106 San Pablo Towne Ctr.
#164, San Pablo CA 94806.
Application Date: Click here to enter a date.
How did you hear about GEMS? Choose an item.
Age: ☐ under 18 ☐ Young Adult 19-29 ☐ Adult 30-59☐ Senior 60+
Student School Level: ☐ High School ☐College ☐ N/A or ☐ I am a … Adult/Parent
School Name: Click here to enter text.
GPA: Click here to enter text.
Grade Level: Choose an item.
Community Service Hours Needed: Click here to enter text.
First Name: Click here to enter text.
Last Name: Click here to enter text.
Address: Click here to enter text.
City: Click here to enter text.
State: Click here to enter text.
Zip Code: Click here to enter text.
Contact Phone: Click here to enter text.
Volunteer Areas of Interest: (check all that apply)
☐ Health & Wellness (Mind/Body/Spirit)
☐ Education & Academics (Core/STEM)
☐ Arts & Culture (Diversity)
☐ Literacy (Life Skills)
Preferred Volunteer Opportunity:
☐ InspireLife Enrichment Program Mentor
☐ STEM– Math Games Coach / Events
☐ Guest Speaker or Workshop Facilitator
☐ Community Outreach / Events Planner
Availability: (*we will let you know of opportunities that are open for dates/times you are available).
Please check dates and enter your available hours: (*most student sessions may occur on Sat. 10-12 / 1-2)
☐ Mon Click here to enter text.
☐ Tue Click here to enter text.
☐ Wed Click here to enter text.
☐ Thu Click here to enter text.
☐ Fri Click here to enter text.
☐ Sat Click here to enter text.
Race/Ethnic Group (optional): ☐African/American ☐ Caucasian ☐ Hispanic/Latino
☐Asian/American ☐Native American ☐Pacific Islander ☐Multi-Cultural
☐ other (indicate here): Click here to enter text.
Veteran: ☐ Non-Veteran: ☐Teacher ☐ Education Staff ☐ Gov. Official ☐
Describe your volunteer experience, if any: Click here to enter text.
Do you have any special skills, hobbies or work experience that may be of benefit in your role as a
volunteer with GEMS? Click here to enter text.
Do you have multi-language skills? ☐yes ☐ no
if so, what other fluent language(s) skills do you have and describe (read, write, and speak capabilities):
Click here to enter text.
What made you decide to join us and what do you hope to get out of becoming a GEMS volunteer?
Click here to enter text.
Please read “DISCLAIMER” before signing. Disclaimer: By signing of this form I, the undersigned, hereby agree to
participate in the “GEMS Programs” and hereby release and hold harmless Gifts Empowered Manifest Success (“GEMS Inc.”), and all
contributing associate business partners and the respective parents, subsidiaries, affiliates, directors, officers, governors, employees and
agents (collectively, the “GEMS Parties”) from and against any and all claims, causes of action, or demands relating to or arising out of
or in connection with my participation in such program, and further agree to indemnify the GEMS Parties for any claims, damages or
causes of action relating to or arising out of any breach of this General Release. Without limiting the foregoing, I hereby release, waive
and discharge any and all claims for death, personal injury or property damage that I may have or that may hereafter accrue to me as a
result of my participation in the program /events or otherwise, and which may be asserted by me or on my behalf against any GEMS
Party.
For GEMS Staff only:
Program Year:
Date Application Accepted:
Background Check Completed:
S ig n a tu re
Fingerprinting Completed:
Assigned Role(s):
X
Date Signed:
Site Location:
Volunteer Day(s)/Time(s):
GENERAL RELEASE
I expressly assume all risk of injury (including, without limitation, permanent disability and death)
relating to, or arising out of, my participation in the event, howsoever caused or arising and whether
by negligence or otherwise, and accept personal responsibility for the damages following such injury,
permanent disability or death.
I grant full permission to the GEMS Parties to use, without further notification, authorization or
compensation to me or anyone on my behalf, my name and likeness, as well as any photographs,
audio, videotapes, motion pictures, recordings, or other record of my participation in the event (or
any excerpt thereof) in any and all media, whether now known or hereafter to become known or
developed, worldwide and in perpetuity, and I represent and warrant that no further permission is
required for the GEMS Parties to use my participation in the event as provided, or otherwise exercise
the rights granted, herein.
I hereby represent and warrant that I have full authority to execute this General Release and grant
the rights granted hereunder, and do so with full knowledge of the facts and circumstances
surrounding my participation in the event and the rights that I am granting herein. I also represent
that I am eighteen (18) years of age or older (or if I am under eighteen (18) years of age, my legal
guardian has signed below in order to consent to all of the foregoing).
I have been given a full opportunity to read this agreement. I fully and completely understand all of
the terms of this agreement and sign it voluntarily, freely, and knowingly. I understand that by
signing this document on behalf of myself (and my child), I (and my child) am giving up important
legal rights and possible claims that I (and/or my child) might otherwise assert or make against any
of the GEMS Parties. I acknowledge and agree that this is a complete RELEASE and DISCHARGE of
all claims and rights of mine and my child’s against the GEMS Parties, and that no action will be
taken by or on behalf of us with respect to any such claims or rights, it being understood that this
release shall be binding upon my heirs, executors, and administrators, and anyone claiming by or
through me.
I acknowledge that I have read and fully understand the foregoing.
BY:
Printed Name ______________________________
Signature _________________________________
_________________________________________
*Parent/Guardian must sign
(if releasee is less than 18 years of age)
Dated: _______________