Teen Volunteer Disclosure Form

Authorized Teen Volunteer Disclosure Form

[Insert Dates]

This form is to be completed for any position involving the supervision or care of minors.  This is being used to provide a safe and secure environment for the activities and programs of [Insert Church Name].

 NAME:  LAST                                   FIRST                                     MIDDLE

*Name of Parent or Guardian if under 18 years:

*If volunteer is under 18 years, the parent or guardian must also sign this form.

ADDRESS:  STREET                                    CITY/STATE                         ZIP CODE

DAYTIME PHONE                                       EVENING PHONE

CELL PHONE                                               EMAIL

DATE OF BIRTH                                          DRIVER’S LICENSE STATE AND NO.

EMERGENCY CONTACT (indicate Name, Tel. No. and Relationship)

__ I have been a member of this church since:

__ I have been a friend of this church since:

WHAT VOLUNTEER ROLE(S) ARE YOU APPLYING FOR?

HAVE YOU SERVED AS A VOLUNTEER AT OUR CHURCH IN THE PAST?  IF SO, PLEASE LIST ROLE(S):

By agreeing to become a volunteer, I have made a commitment to provide a service of both my time and ability.  I shall fulfill my commitment to volunteer as outlined in the position description provided.

I understand that in serving as a volunteer for [Name of Church], I am required to abide by the Safe Conduct Policy and Practice for Youth.  I understand that child abuse is a serious matter and will do my part in the prevention of child abuse while serving.

________________________________________                ___________________________

SIGNATURE                                                                         DATE

I do not know if any reason why my child should not serve as a teen worker with minors.  My child does not demonstrate any signs of being a potential risk to minors.

I hereby release and discharge [Name of Church], together with any of its successors, assigns, employees, or volunteers, from any and all losses, damages, or claims I have or may have in the future arising, directly or indirectly, in any way from my child’s participation as a volunteer.

I hereby agree to indemnify and hold harmless [Name of Church] aan and any of its successors, assigns, employees, or volunteers from any claims made against any or all of them arising, directly or indirectly, in any way out of my child’s participation as a volunteer.

I hereby authorize [Name of Church] or any of its employees or volunteers and any physicians, nurses, EMT personnel or hospital or emergency facility to provide or arrange for any medical services or treatment to my child for injuries or illnesses which may arise during the course of serving as a volunteer.

__________________________________________            ____________________________

PARENT SIGNATURE                                                        DATE

__________________________________________

PARENT NAME PRINTED