Sign Up for the NorCal CoC 2022 Point in Time Count

Your basic info First Name* Last Name* Email* Phone Number*

Your profile Do you have reliable transportation?* If yes, do you have a vehicle you are willing to volunteer for the PIT Count? Are you participating in the count as an individual, or would you like to participate as part of a group?* 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! Have you previously participated in the count? Are you an outreach worker?* If you're not an outreach worker, are you comfortable talking to people whom are experiencing homelessness? Please describe your experience working with those experiencing homelessness.

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

Del Norte
Lassen
Modoc
Plumas
Shasta
Sierra
Siskiyou

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

PIT Volunteer Release Form

By signing below, I hereby agree to hold harmless and release the Continuum of Care; its member organizations, their boards/trustees, employees, volunteers, count organizers; and other participants in the Point-In-Time Count from any liability for any accident, injury or death or any theft or loss of 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 voluntarily assume these and any other risks in participating in the count and waive all claims and causes of action that may arise out of participation in the 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 while a volunteer 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 relevant 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*

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

Additional Information If you have any additional information to add, please do so here: (500 characters or less)