Licensed Clinical Counselors of North Carolina

2025 Committee Interest Form

This Release and Waiver of Liability Waiver is executed by the Licensed Clincial Counselors
of North Carolina.

I, the Volunteer, desire to work as a volunteer for one or more of the Released Parties and engage in the
activities related to being a volunteer.

I, the Volunteer hereby freely, voluntarily and without duress execute this Release under the following
terms:

I, the Volunteer do hereby release and forever discharge and hold harmless the Released Parties and
their successors and assigns from any and all liability, claims and demands.

I understand and acknowledge that by this Release I knowingly assume the risk of injury, harm and loss
associated with the activities.

I also understand that the Released Parties do not assume any responsibility for or obligations to provide
financial assistance or other assistance, including but not limited to medical, health or disability
insurance in the event of injury, illness, death or property damage.

First and Last Name (please print) *

Address *

Phone *

Email *

NC LCMHC License Number

Please attach a CV/resume.

Are you an LCCNC Member?

What LCCNC Committee are you interested in serving?

Would you like to apply for a Committee Chair position?

Have you ever served as a Board member for any other non-profit organization?

Emergency Contact Information

Name

Relationship

Address

Phone