BACK BAY MISSION

HOUSING RECOVERY VOLUNTEER WORK GROUP OPPORTUNITIES For Office Use Only

PARENTAL RELEASE FORM (for volunteers under age 18**)

**NOTE: All work campers must be at least 14yrs. of age PRIOR to date of arrival. Please return to Back Bay Mission, 1012 Division St., Biloxi, MS. 39530 or Fax to: 228-374-2922, at least three weeks before your date of arrival at work project. A volunteer will not be allowed on the construction job site if a signed release form has not been received by Back Bay Mission. Please read before signing, as this constitutes the agreement as a volunteer and the understanding of your working relationship with Back Bay Mission. Name of volunteer: ____________________________________________________ Date of Birth___/___/_____ (Print Name) Mo /Day/Year I hereby give permission for my child to serve in the Housing Recovery project coordinated by Back Bay Mission, a community ministry of the United Church of Christ. In the event of an emergency during the duration of the trip, I hereby give consent to a licensed physician to hospitalize, secure proper treatment, anesthesia and/or surgery for my child named above. I understand that I am responsible for his/her individual medical insurance and will not hold Back Bay Mission or the United Church of Christ liable for any injury or damage to my child while engaged in the volunteer project. Your relationship to participant: ____________________________________________

Health Insurance company: _______________________________________________

Does your child have any physical limitation that might affect his/her work?

________________________________________________________________

List any allergies/medications: _____________________________________________

Date of last tetanus shot: _______________________________________________

Special needs, if any: ____________________________________________________

In addition, I understand that he/she has chosen to travel to the work site to perform housing construction and rehabilitation work, and that my child will be supervised by an approved adult chaperone of the sending organization (e.g. congregation, school, etc.) I understand that this work entails a risk of physical injury and often involves hard physical labor, heavy lifting, and other strenuous activity; and that some activities may take place on ladders and building framing other than ground level. I certify that he/she is in good health and physically able to perform this type of work.

I understand that he/she is engaging in this project at his/her own risk. I assume all risk and responsibility for any damage or injury to my property or any personal injury which he/she may sustain while involved in this project, and related material costs and expenses. Back Bay Mission has arranged accommodations and, I understand that they are not responsible or liable for his/her personal effects and property and will not provide lock up or security for any items. I will hold them harmless in the event of theft or for loss resulting from any source or cause. I further understand that he/she is to abide by whatever rules and regulations may be in effect for the accommodations at that time. By my signature, for myself, my son/daughter, my estate and my heirs, I release, discharge, indemnify and forever hold Back Bay Mission, together with their officers, agents, servants and employees, harmless from any and all causes of action arising from his/her participation in this project, and travel or lodging associated therewith, including any damages which may be caused by their own negligence.

Volunteer Signature: Date: _______________________________________________ Parent/Guardian Signature: Date: __________________________________________ Witness: _______________________________________________ Date of Planned Work Trip: _______________________________________________ Name of Sending Church or Organization: Livingston CARES

PHOTO RELEASE AUTHORIZATION

I also hereby grant permission to Back Bay Mission to use photographs of my child for reproduction on the Mission’s web site or in any other official publications and displays without further consideration or compensation, and I acknowledge the Mission’s right to crop or treat the photographs at its discretion. I further agree to the use of my child’s name in any or all photographic renderings. Volunteer Signature: __________________________________ Date: __________________ Parent/ Guardian Signature: _______________________________ Date:_________________ Witness: __________________________ Date of Planned Work Trip: __________________ Name of Sending Church or Organization: Livingston CARES