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 Shepherd of the Hills Presbyterian Church Disaster Response and
all Faith based sponsoring organizations. 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
the parties above 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
Shepherd
of the Hills Disaster Response Coordinator
1015
North Sunset Canyon Drive, Dripping Springs, TX 78620 Office: (512) 892-6800 / Fax: (512) 288-5595