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700 Tabor St.,,
Waveland, Ms. 39576
Phone: (228) 466-4630
Cell: (228) 209-8822
PARENTAL RELEASE FORM
(FOR VOLUNTEERS UNDER AGE 18)
Name of volunteer:_______________________________________________________
I hereby give permission for my child to serve in repair/rebuilding or clean-up of homes with Katrina Relief thru the City of Waveland Long Term Recovery Office. In the event of an emergency during the duration of the trip, I hereby give consent to a licensed physician to hospitalize, secure proper treatment, anesthesia and or surgery for my child named above.
I understand that I am responsible for his/her own medical insurance and will not hold Your Agency liable for any injury or damage to my child while engaged in the disaster response project.
Parent/Guardian Signature:__________________________________________________
Home Telephone:________________ Work Telephone:___________________________
Your relationship to participant:______________________________________________
Insurance company:_______________________________________________________
Does your child have any physical limitation that might affect his/her work?__________ ________________________________________________________________________
List any allergies/medications:_______________________________________________
______________________________________________________________________
Date of last tetanus shot:____________________________________________________
Special needs if any:_______________________________________________________
________________________________________________________________________
________________________________________________________________________
Volunteer’s Signature:_____________________________________________________
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