Volunteer Name & SS#: ________________________________________ D.O.B._______________________
Address: ___________________________________ City/State/Zip: ________________________________
Name & SS# of Parent(s)/Guardian(s)/Custodian(s): ______________________________________________
_______________________________________________________________________________________
School: _____________________________ Grade: _____________________ Age: ____________________
As parent(s)/legal guardian(s)/custodian(s) of this youth, I/We permit to participate in all official supervised
American Human Helping Hand, Inc., programs and activities for which he/she is registered or participates
(when no registration is required). 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 youth named above in connection with any such program or activity.
In the event, I/We cannot be reached to make arrangements for emergency medical attention I/We authorize the
President or Vice-President (or designated event supervisor) to administer or authorize the administration of
emergency medical treatment in case of illness or injury to the youth named above.
In case of emergency, I can be notified at:
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:
_______________________________________________________________________________________
_________________________________ ________________________________
Parent/Guardian/Custodian Signature Parent/Guardian/Custodian Signature
Subscribed and sworn before me on this ______ day of __________________________, 20_____.
Notary Public: ____________________________________________
For the State of Texas
My commission expires: _____________________________________
Permission/Medical/General Information Youth Volunteer Release Form
For
American Human Helping Hand, Inc.
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