Application Form for Brown Girl Surf Volunteers
PLEASE RETURN THIS APPLICATION FORM BY SAVING, SCANNING OR PHOTOGRAPHING IT AND EMAILING IT TO [email protected],
OR TEXTING IT TO 510 239 7565. BOTH PAGES ARE REQUIRED FOR THE SURF VOLUNTEER PROGRAM (INCLUDING TRANSPORT TEAM)
Participant __________________________________________________________________________ ____/____/____
First
Middle
Last
Birth Date
______
Age
______
Gender
Address__________________________________________________________________________________________________________
Street
City
State
Zip
Phone Best: (______)_____________________________ (alternate) (______)________________________ Email_______________________________________
Ethnic Background:
□African descent □Arab
□Asian descent □European descent □Latina/o □Native American □Pacific Islander □Additional Description______________
Profession:
____________________________________________________________________________
EMERGENCY CONTACT
Name_________________________________________________________
First
Relationship ______________________________________
Last
Phones _______________________________________________________________________________________________________________
Home Phone
Work Phone
Cell Phone
MEDICAL INFORMATION
Please explain any medical or special needs: □ Allergies □ Medications
□ Physical Limitations □ Diet Restrictions
______________________________________________________________________________________________________________________
Doctor __________________________Clinic/Office Phones (_____)________________ (_____)_________________ (_____)__________________
Doctor
Clinic
After Hours
Medical Insurance Carrier__________________________________ Policy # _______________
Release of Liability for Brown Girl Surf, and the Social Good Fund (fiscal sponsor of Brown Girl Surf)
I defend, hold harmless and release from all liability Brown Girl Surf, the Social Good Fund, The city of Half Moon Bay, its elected officials and appointed officials,
agent, employees, and volunteers, from all lawsuits, damages, claims, judgments, losses. Liability or expenses arising of (1) death or personal injury or property
damage to myself, my child, or my ward, which may be sustained while taking a surfing lesson with Brown Girl Surf (a project of the Social Good Fund), or (2) death or
injury which results or increase by any action taken to medically treat me, my child, or my ward. All of the terms above shall apply whether or not caused by the
alleged negligence, whether active or passive, or any acts or omissions of Brown Girl Surf, the Social Good Fund, the city of Half Moon Bay, or any of its elected or
appointed officers, agents, employees, or volunteers. I have read, understand and approve the Release of Liability. If the participant is a minor, the undersigned
parent or legal guardian warrants and represents that this Release, its significance and the assumption of risk, has been explained to and understand by my minor
child or ward. I hereby declare, under penalty or perjury, that I am the parent or legal guardian of the named participant. I give permission for any medical care that
the staff of Brown Girl Surf, or the Social Good Fund deem necessary. I agree to let Brown Girl Surf and the Social Good Fund use my or my child’s name and likeness
free of charge and in any manner for any lawful purpose including in its publications and website and/or other publications for the purpose of documenting and
promoting use of Brown Girl Surf and the Social Good Fund services and programs. This release applies to all programs and events sponsored by Brown Girl Surf , its
agents, employees, and volunteers. This release is made in all my legal capacities, including on my own behalf, and on the behalf of my spouse and any other parent
or guardian of the enrollee, and as legal representative and guardian of the enrollee.
Volunteer’s Name
Volunteer’s Signature_____________________________________________________________________________
Date:_________
Surf Volunteer Program Application Questions
Name:______________________________
Please read program descriptions at http://www.browngirlsurf.com/surf-volunteer-programs before answering the following question.
I am Interested in (please check one):
____Transportation Team
____Volunteer Surf Instructor
____ Leadership Crew
Why do you want to volunteer with Brown Girl Surf?
If you have volunteered with BGS before, let us know what you’ve done and approximately when.
What experiences do you have that equip you to effectively work with our participants, who are largely low and middle income girls and women of
color from the East Bay.
What experiences do you have working in education, youth development, outdoor education, coaching, or related fields. (it’s OK to attach a
resume and say see resume)
What other skills do you have that you might be excited to share?
What is your relationship to the Oakland community. (for example: do you live in or near Oakland, work in Oakland, have community/family
connections, spend time here, etc) ?
How many times have you surfed in your life (circle one)
Less than 5 times
5-10 times
10-20 times.
20 to 50 times
50 – 150 times.
More than 150 times.
Describe your ability level as a surfer. If its relevant, let us know where you feel comfortable surfing and under what conditions. (You do NOT need
to be a highly experienced surfer to be a Surf Volunteer. However, it is helpful for us to understand the range of skills on the team we are
selecting)
Volunteer Agreements (please initial and sign)
_______I have read the descriptions of the Surf Volunteer position online and am ready to undertake the training and fulfill the requirements and
responsibilities for the position.
_______I understand that after training and before I can work with girls, I will need to undergo a background check relevant to working with youth.
Brown Girl Surf will cover the cost of this. Events that directly relate to safety, violence and children are the top concern, and the focus will be on
the last 7 years.
_______I understand that the volunteer relationship is dependent on my fulfillment of volunteer expectations and can be terminated at any time
and for any reason by the staff of Brown Girl Surf.
Volunteer’s Name
Volunteer’s Signature_____________________________________________________________________________
Date:_________