Minor Waiver Form

PLEASE PRINT and bring with you when you Volunteer.

Release and Waiver of Liability
MINOR

This Release and Waiver of Liability (the “Release”) is executed on this _____ day of ______________, 2016 by __________________________________________, a minor child (the “Volunteer”) and _____________________________________ the parent having legal custody and/or the legal guardian of the

Volunteer (the “Guardian”), in favor of Habitat for Humanity International, Inc., a non profit corporation, and Habitat for Humanity of Greater Lowell INC., a Massachusetts nonprofit corporation, its directors, officers, employees (collectively, “Habitat”).

The Volunteer and Guardian desire that the Volunteer works as a volunteer for Habitat and engages in the activities related to being a volunteer. The Volunteer and the Guardian understand that the activities may include constructing and rehabilitating residential buildings, working in the Habitat offices and living in housing provided for volunteers of Habitat.

The Volunteer and Guardian do hereby freely, voluntarily and without duress execute this Release under the following terms:

WAIVER AND RELEASE. Volunteer and Guardian do hereby release and forever discharge and hold harmless Habitat and its successors and assigns from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from Volunteer’s work for Habitat.

Volunteer and Guardian understand that this Release discharges Habitat from any liability or claim that the Volunteer or Guardian may have against Habitat with respect to any bodily injury, personal injury, illness, death or property damage that may result from Volunteer’s work for Habitat, whether caused by the negligence of Habitat or its officers, directors, employees, or agents or otherwise. Volunteer and Guardian also understand that Habitat does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury or illness.

MEDICAL TREATMENT. Volunteer and Guardian do hereby release and forever discharge Habitat from any claim whatsoever that arises or may hereafter arise on account of any first aid, treatment or service rendered in connection with the Volunteer’s work for Habitat or with the decision by any representative or agent of Habitat to exercise the power to consent to medical or dental treatment as such power may be granted and authorized in the Parental Authorization for Treatment of a Minor Child.

ASSUMPTION OF THE RISK. The Volunteer and Guardian understand that the work for Habitat may include activities that may be hazardous to the Volunteer, including, but not limited to, construction, loading and unloading and transportation to and from the work sites.

Volunteer and Guardian hereby expressly and specifically assume the risk of injury or harm in these activities and releases Habitat from all liability for injury, illness, death or property damage resulting from the activities of the Volunteer’s work for Habitat.

INSURANCE. The Volunteer and Guardian understand that, except as otherwise agreed to by Habitat in writing, Habitat does not carry or maintain health, medical, or disability insurance coverage for any Volunteer.

Each Volunteer is expected and encouraged to obtain his or her own medical or health insurance coverage.

PHOTOGRAPHIC RELEASE. Volunteer and Guardian do hereby grant and convey unto Habitat all right, title and interest in any and all photographic images and video or audio recordings made by Habitat during the Volunteer’s work for Habitat, including, but not limited to, any royalties, proceeds or other benefits derived from such photographs or recordings.

OTHER. Volunteer and Guardian expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Massachusetts, and that this Release shall be governed by and interpreted in accordance with the laws of the Commonwealth of Massachusetts. Volunteer and Guardian agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable. 

Parental Authorization for Treatment of a Minor

 I, _______________________________________, am the parent or legal guardian having custody of ________________________________________, a minor child. As such parent or legal guardian, I hereby authorize and

appoint _____________________________________, an adult in whose care the minor child has been entrusted or a duly

authorized agent of Habitat for Humanity of Greater Lowell, Inc. as my agent to act for me with respect to my minor child, ______________________________, and in my name in any way I could act in person to make any and all decisions for me

with respect to my minor child, __________________________________________, concerning my minor child’s personal care, medical treatment, hospitalization and health care and to require, withhold or withdraw any type of medical treatment or procedure, including x-ray examination, anesthetic, medical or surgical diagnosis of treatment which may be rendered to my minor child under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state in which

treatment is sought. My agent shall have the same access to my minor child’s medical records that I have, including the right to disclose the contents to others.

 IN WITNESS WHEREOF, Volunteer and Guardian have executed this Release as of the day and year first above written.

Volunteer:___________________________________
Witness: ____________________________________
Parent/Guardian:______________________________
Witness: ____________________________________

Emergency Information                                                 PLEASE PRINT CLEARLY!!!

In case of emergency please contact:

Name:_________________________________________
Relationship: ____________________________________

Street:_______________________________________City: ________________________ State: _______

Phone (home):_______________________ (work):_______________________
(cell)______________________________

Emergency Medical Information

The following information may be needed by any hospital or medical practitioner not having access to the Volunteer/Participant’s medical history:

Allergies(medicines,food,insect,plants): _____________________________________________________________________________________
_____________________________________________________________________________________

Medication being taken: _____________________________________________________________________________________
_____________________________________________________________________________________

Date of last tetanus shot:_________________________________

Physical impairments: _____________________________________________________________________________________

Other: ________________________________________________________________________________

Personal Physician:

Name: _______________________________________________

Address:______________________________________________
Phone: _______________________________________________

Insurance Company: _____________________________________

Policy number: _________________________________________