Name of volunteer: _______________________________________________________

I hereby give permission for my child to serve in Disaster Response, "Hands of Help Projects", and Humanitarian relief 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 "Projects".

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: _______________________________________________________

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Volunteer Signature: ______________________________ Date: __________________

RETURN TO:

Singletary H. Snyder

Mission Presbytery Disaster Response Coordinator, Mission Presbytery

13110 Hwy 290 W., Suite 200

Austin, Texas 78737

(512) 892-6800 / Fax: (512) 288-5595