Please fill in and submit the form. All questions are required.

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PERSONAL INFORMATION

First Name:
Last Name:
Phone:
Email:
Emergency Contact Name:
Emergency Contact Phone:
Have you ever volunteered for the Lee County Library System before? If yes, what location?	Not a Prior Volunteer Bonita Springs Cape Coral Captiva Dunbar East County Fandom Fest Fort Myers Johann Fust Lakes North Fort Myers Northwest Pine Island Reading Festival Riverdale South County
IP

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SHIFT SELECTION

Shift Selection (select all that apply):

Saturday, Dec. 14, from 10 a.m. to 4 p.m. (6 hours) Saturday, Dec. 14, from 10 a.m. to 2 p.m. (4 hours) Saturday, Dec. 14, from Noon to 4 p.m. (4 hours)

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WORKERS' COMPENSATION FOR VOLUNTEERS

Volunteers are covered under Lee County’s Workers’ Compensation Program for work related injuries which occur while a person is volunteering. The accident and injury procedures are as follows:

An accident or injury must be reported immediately to the supervisor of your assigned venue. The supervisor is required to complete an Injury Report and submit it to Risk Management and Library Administration promptly.

If the injury appears LIFE THREATENING, call 9-1-1 and have the person transported to the nearest medical facility. For injuries that are not life-threatening and occur Monday through Friday 7:30 AM to 4:30 PM, the volunteer MUST obtain authorization through Risk Management at 239-533-2309 or 533-2310 or Employee Health Services at 239-533-2067.

If an injury occurs outside of the hours mentioned above, the volunteer should obtain medical treatment at Lee Convenient Care Center; 4771 S. Cleveland Ave., Fort Myers, phone number is 239-343-9800. Again, in all cases, the supervisor must be notified immediately. The Lee County Workers’ Compensation Program is a managed-care arrangement that relies on referrals from an authorized medical care coordinator for medical treatment.

If a volunteer seeks treatment through his or her own physician or declines to be treated at the time of injury or accident, benefits may not be paid.

Please Select One Yes, I acknowledge and understand. No, I do not agree.

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PHOTO RELEASE

I agree to allow myself to participate in and to be photographed or videotaped for publication purposes involving the Lee County Library System or the Southwest Florida Reading Festival.

I give the Lee County Library System the absolute right to use, re-use and publish without restriction photographic pictures and/or video of myself for art, advertising, or other purpose.

I also consent to the use of any printed matter in conjunction therewith.

I indemnify and hold harmless Lee County and any employee of Lee County against any and all claims arising from the use of my photograph and/or video, and will further indemnify and “hold harmless” the County, its employees or agents against our participation in the event, from and against all costs, expenses and liabilities resulting from any claim brought thereon to the extent of the County’s liability under general law.

Please Select One Yes, I consent. No, I do not consent.