Day of Caring Project Request Form

A Certificate of Insurance (COI) is REQUIRED EVERY YEAR to fulfill project request. The certificate holder should be listed as Jackson County United Way. Without this form, your project WILL NOT BE considered. This can be acquired for free from your insurance agent and they can:
  • Mail to PO Box 94 Seymour, IN 47274
  • Or email to Emily Engelking at emily@jacsy.org  

Projects will be completed between 9:00 AM-4:00 PM on the Day of Caring. You MUST be onsite during the time your volunteers are there or your project WILL NOT be completed.
Please list the address of the location of this project (if different from your own)
Project Information
Please fill out the information below to the best of your ability for an OUTDOOR project only. After receiving your request form, we will contact you to let you know if your project is NOT ABLE to be completed during the Day of Caring. If it is accepted, a surveyor will reach out to you about stopping by to survey the project and confirm the materials you will be providing. Please note that the Jackson County United Way is not able to assist with funds for lumber, paint, or other building materials.

Note: NO ramps, roofing, plumbing, electrical, large tree removal, or foundation projects will be considered.
Please give your best guess. Our survey crew will determine the correct number when they come to look at your project if it is within our program scope.
Such as flowers, rock, mulch, etc.
Such as gloves, shovels, basic tools, etc.

Please make any notes or volunteer group requests here. 

CUMMINS EMPLOYEES: Please list your WID or Cummins email 

If requesting for someone other than self, please list your name, phone number, and relationship to host site requestor.

Project Release of Liability Waiver
I am the owner and occupant of the above listed property. I give permission to volunteers from Jackson County United Way Day of Caring to work on my property for the purpose of the projects described above. I understand that these are not professionals working for profit, and that no warranty is made as to the quality of work done. 

In consideration of the volunteer services to be rendered to me or my property by the volunteers, I the undersigned, release and agree to hold harmless Jackson County United Way, its staff, volunteers, representatives and any related agency from liability, injury, damages, accident delay or irregularity related to the aforementioned volunteer services. 

This release covers all rights and causes of action of every kind, nature and description, which the undersigned ever had, now has, or but for this release, may have. This release binds the undersigned and his/her heirs, representatives and assignees.

Consent to Use and Publication of Image 
In consideration of participation in Jackson County United Way Day of Caring, I hereby give Jackson County United Way the absolute, unconditional, and irrevocable right and permission to use my name and to use, reproduce, edit, exhibit, project, display, copyright, and publish, photographic images and/or moving pictures and/or videotaped images of me with or without voice, in which I am included, in whole or in part, photographed, taped, videotaped, and/or recorded prior to, during, and/or after the Jackson County United Way Day of Caring project and, to circulate same in any and all forms and media for art, advertising, trade purposes, and competition, of every description and any other lawful purpose whatsoever, and I hereby consent to the use of all printed matter in conjunction therewith and waive all rights to inspect and/or to approve drafts, finished products, and/or editorial, promotional, and printed copy, and/or sound tracks, and hereby discharge and agree to hold Jackson County United Way, its staff, volunteers, and representatives harmless and fully indemnify Jackson County United Way Day of Caring from and against any and all claims arising by virtue of any blurring, distortion, alteration, optical illusion, or use in composite from, whether intentional or otherwise, that may occur or be produced in the production, processing, duplication, projecting, or displaying of said images of me and from any and all Claims for violation of any personal and all proprietary rights of that I may have or may claim to have in connection with such images and with the production, alteration, use, distribution, and disposition thereof. This consent will remain in effect until the owner revokes via a written notice.