Parent/Guardian Permission - Hospice Volunteers of Hancock County

Parent/Guardian Permission Form

"*" indicates required fields

Name*

First Last

Phone*

Email*

I give permission for my child to participate in the Hospice Volunteers of Hancock County Yard Clean Up Service Project. I understand that participation may include traveling with HVHC Adult Volunteers to the home of an HVHC patient and performing outdoor yard clean up activities such as raking, picking up leaves and debris, light weeding, and other tasks appropriate for the project. I understand that my child will receive safety instructions and will be supervised by HVHC staff and/or HVHC Adult Volunteers. I understand that my child is expected to follow all safety instructions and directions provided by HVHC.

Parents Initials*

Allergies, Health & Safety Information

Please offer any information that would help us provide a safe experience for your child. We will be providing snacks and lunch for your child.

IF THERE IS NOTHING TO REPORT PLEASE WRITE "NONE"

Allergies*

Dietary Restrictions*

Physical Limitations or Activity Restrictions*

Other Information We Should Know*

Emergency Contact (other than you)

Name*

Relationship to Student*

Phone*

Emergency Medical Authorization

In the event of an emergency involving my child, I authorize Hospice Volunteers of Hancock County staff or designated HVHC Adult Volunteer to seek appropriate emergency medical assistance and to contact me or the emergency contact listed above. I understand that every effort will be made to contact a parent/guardian as soon as reasonably possible.

Parents Initials*

Liability & Assumption of Risk

I understand that outdoor yard clean up activities involves risk, including but not limited to uneven ground, slips and falls, weather conditions, insects, plants, tools and equipment, lifting or moving materials and other hazards associated with outdoor work.

I understand that HVHC will provide safety instructions and appropriate supervision, but that participation in outdoor activities involves risks that cannot be completely eliminated.

I voluntarily give permission for my child to participate in this project and, to the extent permitted by law, agree to release and hold harmless Hospice Volunteers of Hancock County, its employees, board members, volunteers, and designated project leaders from claims arising from my child’s participation, except to the extent caused by their gross negligence or intentional misconduct.

Parent/Guardian Initials*

Privacy & Confidentiality

I understand that my child is participating in this project and will visit the homes of HVHC patients and may become aware of personal or private information about patients and their families.

I understand that my child is expected to respect the privacy, dignity, and confidentiality of patients and their families.

My child agrees not to share or post patients names, addresses, personal information, medical information, photographs, stories, or other identifying information about patients and their families with others outside the project.

Parent/Guardian Initials*

Photo & Video Release

HVHC may take photographs or video during the yard clean up service project for the use in educational materials, newsletter, social media, website, community presentations, or other HVHC communications.

Photo & Video Permission*

Please select one

YES - I give permission for HVHC to photograph or record my child and use those for HVHC communications.

NO - I do not give permission for HVHC to photograph or record my child for these purposes. I understand that choosing not to give photo/video permission will not affect my child's ability to participate in the project.

Parent/Guardian Initials*

Parent/Guardian Acknowledgement

By signing below, I confirm that:

I am the parent or legal guardian of the child named above.
I have read and understand this form.
I give permission for my child to participate in HVHC yard clean up service project.
I understand the nature of the activities and the risks associated with outdoor yard work.

Signature*