Permission/Medical/General Information Volunteer Release Form
For
American Human Helping Hand, Inc.
|
Volunteer Name: ___________________________________________ D.O.B.___________________
Social Security Number: ___________________________ ID/DL #: ____________________________
Address: ______________________________________ City/State/Zip: ________________________
Contact Number: __________________________ Email: _____________________________________
I/we knowingly release; absolve, indemnify, and hold harmless American Human Helping Hand, Inc., its
Members, Trustees, Administrative Board, Committees and Staff, as well as the organizers, sponsors, workers
and all others acting on behalf of American Human Helping Hand, Inc., or its programs and activities, from all
claims that might result from any accident, personal injury, illness or death to the myself named above in
connection with any such program or activity.
In case of emergency, notify: ___________________________________________________________
Address: _____________________________________ City/State/Zip: _________________________
Home Phone: ________________________________ Cell Phone: _____________________________
Family Physician: ___________________________________ Phone: ___________________________
Name of Medical Insurance: _______________________________ Policy No: ____________________
All Medications Presently Taken: ________________________________________________________
Allergies: __________________________________________________________________________
Date of Last Tetanus Shot: ___________________________
List any previous illness, injuries, medical conditions, or special needs the staff should be aware:
__________________________________________________________________________________
_______________________________
Volunteer Signature
Subscribed and sworn before me on this ______ day of ____________________________, 20______.
Notary Public: _________________________________________
For the State of Texas
My commission expires: __________________________________