[Bxscience Key Club] Re: Interested in volunteering at a soup kitchen?

Youth Liability Waiver
Participant's Name: __________________________________________________________
Address: ____________________________________________________________________
City: _________________________________ State: _______________ Zip:______________
Email: _______________________________________________________________________
Date of Birth: ____________________ Age: ________ Gender: __________________
Emergency Contact Person: ______________________ Relationship: __________________
Emergency Contact Number: _________________ Parent Email_____________________
School Name:______________________________________________Grade_________________
Date of Service____________________________________________________________________
How did you hear about this opportunity?_____________________________________________
Have you served with StudentsforService before and on which projects?
______________________________________________________________________________________
Are you interested in serving as a Team Leader for this project:___________. Being a Team Leader
requires attendance at a planning meeting in late April and additional responsibilities at the service
day. Interested students will notified by email with dates for the planning meeting.
Participation Waiver for May 19th Service Day with NYCCAH
I, _______________________________________, understand that I am:
• spending time as a volunteer on projects organized by NYCCAH with non-profit groups or participating in a NYCCAH event
or function.
• responsible for my behavior, and I will only perform volunteer work that I am comfortable doing or participate in activities that I
am comfortable doing.
• I hereby acknowledge that StudentsforService is not an operator of any program in which participant shall be placed and
knowingly, freely and voluntarily waive any right or cause of action of any kind against StudentsforService in connection with this
program.
• grant permission for StudentsforService, their service partners, and or/ sponsors to use any photos, film, digital imaging, videos,
verbal and written statements of the above stated participant or their likeness for promotional, web usage or other uses either
associated with the program, a project, event or function or otherwise.
. Signature of Participant: __________________________ Date: _________
. Signature of Parent: _____________________________ Date: _________
IMPORTANT:
Please return this signed waiver by email to info@studentsforservice.org or fax to 212-799-7936. An
email confirming your registration will be sent to you upon our receipt of your completed waiver.


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Bronx Science Key Club Board 2011-2012:
Victoria Li '12, President
Jaehwi Kwon '13, Vice President
Jessica Chan '13, Secretary
Michelle Soto '12, Treasurer
Naurin Shaki '13, Editor
 
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