Flint Hills Volunteer Center Parent/Legal Guardian Waiver

CSC Parent/Legal Guardian Waiver

Step 1 of 3

Student Volunteer's Name*
THIS IS A LEGAL DOCUMENT. PLEASE READ CAREFULLY.*
Please check each box for acknowledgement of agreement.
- Select All
- Risk Disclosure: I understand that adult supervisors will accompany my child on all group projects and activities. I also understand that the supervisors may be volunteers and that the project or activity will involve the normal level of risk associated with such a project or activity. I agree that this form shall waive any rights, claims of responsibility or liability, or cause of action resulting from personal injury to my child in the CSC program through group or individual volunteering and agree to indemnify the partner agency and its employees or representatives from any such claims.
- Medical Care Authorization: At any time due to such circumstances as accident or sudden illness I hereby give permission for emergency medical treatment to be obtained for my child. I understand that a CSC representative or the partner agency will call me prior to leaving or upon arrival at the emergency destination, and that I will be responsible for all related expenses incurred (i.e. ambulance or taxi costs, etc.).
- Photographic Release: In the event my child is photographed or filmed for promotional purposes while participating in a CSC project, the photo or video may be used by CSC or any of its related agencies for promotional purposes.
- Parent/Legal Guardian Responsibility: I will inform CSC of any special need or condition my child has. I understand withholding this information is unfair to my child and to the CSC leader entrusted with my child’s safety. I will be punctual when dropping off/picking up my child from projects, both for his/her safety and as a courtesy to CSC and its partner agencies. I understand that violating these policies may lead to my child’s exclusion from CSC programs.

Emergency Contact #1 (If we are unable to reach you)*
First Last
Emergency Contact #1 Phone*
Emergency Contact #2 (If we are unable to reach #1)*
First Last
Emergency Contact #2 Phone*
Health Care Provider/Family Physician*
Phone
Does your child have any allergies?*
- No
- Yes
If yes, please explain.
Is your child currently under medical care?*
- No
- Yes
If yes, please explain.
Please list any mental or physical condition(s) your child has that we should be aware of and any medications s/he is taking.

Acknowledgement
Please note, this information is kept confidential and will not affect the student’s ability to participate in CSC programming. It is collected for anonymous grant reporting and program improvement purposes only.
By typing your name and dating, you are acknowledging that you have read and understand this waiver, agree to its provisions, affirm that you are the parent/legal guardian of the above name child, and verify that all information you have given is correct.*
Date*
MM slash DD slash YYYY

CSC Parent/Legal Guardian Waiver

Step 1 of 3

Acknowledgement