Consent Form for a Minor to Volunteer and
Obtain Emergency Medical Treatment
(to be completed by a parent, guardian, or legal custodian)
Department: ______________________________________________ Date: ______________
Volunteer Site Coordinator:
Parent, Guardian, or Legal Custodian Contact Information:
Name
Home Address
Home Phone Cell Phone
Work Phone
Other Emergency Name and Number _______________________________________________
Full Name of Minor
Minor’s Address ________________________________________________________________
Telephone
Consent for Participation:
I, , hereby give permission for
(print name of parent, guardian, or legal custodian)
_____________________________________________ to participate as a volunteer in
(print name of minor)
Pinellas County’s Volunteer Services Program.
Consent for Emergency Medical Treatment:
I, , further consent that Pinellas County,
(print name of parent, guardian, or legal custodian)
its applicable department or division, obtain necessary emergency medical treatment and/or
transportation for in the event of an accident, injury,
(print name of minor)
or sudden illness while said minor is engaged in the Pinellas County Volunteer Services Program.
(continued)
www.pinellascounty.org/volunteer 9/27/18
