Sign Up for the Solano County 2022 PIT Count

Your basic info First Name* Last Name* Email* Phone* Agency (if applicable)

Additional info Are you participating in the count as an individual, or would you like to participate as part of a group?* Group / Team Selection: If you are hoping to volunteer with family or friends, please choose a team name and have them use the same name when they register - this will help us to pair you up for the count! Would you be comfortable assuming the risk of being in the same car with the people in your group? We assign individuals to small teams. If necessary, would you be comfortable being in a car with a randomly assigned teammate or would you prefer to only be assigned to a location where you will be walking outside with a masked teammate? Are you an outreach worker?* Are you comfortable speaking with the homeless population?

Your profile Do you have a vehicle that you are willing to volunteer to drive for the PIT Count? Have you previously participated in the count?* Are you willing to be a team leader? Responsibilities might include choosing a meet-up location, confirming everyone on your team is set up with the mobile app including necessary personal protective equipment (PPE), and at the end of the count confirming everyone on the team has submitted all survey. Are you willing to volunteer to count on a weekend?

COVID-19 Concerns

Your safety is our priority. We expect all volunteers to be following local health guidelines. Please answer the following questions based on your own personal comfort level with risk of transmission:

Are you in need of PPE for yourself? Would you like to be assigned a role with lower risk? Please add any additional information you'd like to share about what would help you feel more comfortable volunteering for the PIT Count this year.

Count Area What is your primary choice of count area?* What other count areas would you be willing to volunteer? (Select all that apply)

Benicia
Dixon
Fairfield
Rio Vista
Suisun City
Unavailable
Vacaville
Vallejo

* Unless notified you will be reporting to the count area of your first preference. Thank you for your flexibility.

Emergency Contact While we do not expect issues, we ask that volunteers identify an emergency contact. Emergency Contact Name* Emergency Contact Relationship* Emergency Contact Number*

Additional Information Please add any other information you'd like the event organizers to know.

Confidentiality Policy or Release Forms (e-sign)

By signing below, I hereby agree to hold harmless and release the Continuum of Care; its member organizations, their boards/trustees, officials, employees, volunteers, count organizers; and other participants in the Point-In-Time Count, including any homeless individuals subject to the count (together, the "CoC Parties"), from any claims, liability or demands, either in law or equity, for any accident, injury, or death, including any COVID-19 related illness or condition (whether infection occurs before, during, or after participation in the Program), or any theft or loss of or damage to property arising from the participation as a Volunteer in the Point-In- Time Count, regardless of whether incurred as a result of negligence or other.

I understand that there are additional health risks due to the novel coronavirus, COVID-19, which is extremely contagious and believed to spread primarily from person-to-person contact. Having full knowledge of these risks, I voluntarily assume the risk that I may be exposed to or infected by COVID-19 by my voluntary participation in the Point-In-Time Count, and that such exposure or infection may result in personal injury, illness, disability, and death, as well as transmission of COVID-19 to other individuals. I agree to follow federal, state and county public health guidelines while conducting the Point-in-Time Count and participating in any forms of associated Point-in-Time activities. I further agree to self-monitor for signs and symptoms of COVID-19, and to notify the Continuum of Care if I experience symptoms within 14 days after conducting the Point-in-Time Count.

If I am a driver or passenger in a vehicle as part of my participation in the Point-in-Time Count, I understand and agree that accidents can occur as part of a vehicle trip during the Point-In-Time Count and that, as a result, I may sustain serious or fatal injuries or damage to my personal property. I further understand and agree that being in a vehicle with other persons results in a heightened risk that I may be exposed to or infected by COVID-19 and suffer illness or death as a result. I voluntarily assume these and any other risks in participating in the Point-in-Time Count, and expressly waive and discharge in advance all claims and causes of action that I or my successors in interest may have against the CoC parties arising out of my participation in the Point-In-Time Count.

I have agreed to serve as a volunteer for the Point-In-Time Count. I understand that as a volunteer for the Point-In-Time Count it will be necessary for me to handle and process confidential information. I acknowledge that I will keep all information confidential and that it is my responsibility to keep this information confidential even after I end my volunteer duties for the Point-In-Time Count. I understand that I am not to disclose any identifying confidential information and/or records or to engage in casual or informal conversation identifying any individual involved in the count.

I have read and fully comprehend the information pertained in this form and agree to the terms of this release. By signing below, I acknowledge that it is my responsibility to comply with all laws, policies, and regulations concerning access, use, maintenance and disclosure of information made available to me as a volunteer in the Point-In-Time Count.

Volunteer Signature* Volunteer Signature Date*