Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Number *

(###)

###

####

Are you currently employed? *

Yes

No

Do you have reliable transportation? *

Yes

No

Have you ever been convicted of a crime? *

Yes

No

Are you currently facing any criminal charges? *

Yes

No

Are you on parole or probation? *

Yes

No

Are you authorized to work lawfully in the United States? *

Yes

No

To fully qualify for any job placement or free skills training opportunities, all individuals must voluntarily participate in 12 months of case management with the Zan W Holmes Jr. Community Outreach Center. *

I do not have any medical ailments, physical limitations, or mental disabilities that will affect my ability to participate in the low voltage program.

I forever release Zan W Holmes Jr. Community Outreach Center from any and all claims and causes of action that they or their representatives now have or may have in the future for personal injury, property damage or wrongful death occurring to me, arising out of participation in the low voltage program.

PHOTO CONSENT
Submission of this form gives Zan Wesley Holmes, Jr. Community Outreach Center permission to capture and display photos of the event and its participants for professional promotional purposes. We own all rights to photos taken. *

I agree

COVID-19 WAIVER
I acknowledge that I must comply with all set procedures by Zan W Holmes Jr. Community Outreach Center to reduce the spread of all Covid variants while on the premises. I attest that I hereby release and agree to hold Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the center, or that may otherwise arise in any way in connection with any services received from Zan Wesley Holmes Jr Community Outreach Center or any other collaborating partner. I understand that this release discharges Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner have against our organizations with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services from Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner This liability waiver and release extends to the center together with all owners, partners, and employees. *

I agree