PARENTAL RELEASE FORM
(MPDR5)
(For volunteers under the age of
18)
Name
of volunteer: _______________________________________________________
I
hereby give permission for my child to serve in the Disaster Response project
coordinated by Mission Presbytery Disaster Response and Mission Presbytery. 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 I am responsible for his/her own medical insurance and will not hold
Mission Presbytery Disaster Response or Mission Presbytery liable for any
injury or damage to my child while engaged in the disaster 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
Signature: ______________________________ Date: __________________
RETURN
TO:
Singletary
H. Snyder
Mission
Presbytery Disaster Response Coordinator, Mission Presbytery
1015
North Sunset Canyon Drive, Dripping Springs, Texas 78620
(512)
892-6800 / Fax: (512) 288-5595