Volunteer Job Shadow Parent Consent And Release Of Liability Form

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Volunteer/Job Shadow Parent Consent and Release of Liability Form
If volunteer/shadower is under of the age of 18, parental guardian consent is required.
My son/daughter, _______________________, has my permission to serve as a KentuckyOne Teen
Volunteer and/or participate in the KentuckyOne Health Job Shadow experience. As the
parent/guardian of the above-named student, I will read the literature that is provided to my child so
that I know what will be expected of him/her.
I attest that my child is at least 14 years of age (Volunteer Program) or 16 years of age (Job
Shadower Program) and is free from communicable diseases and will be able to provide evidence of
negative TB screening and proof of immunization (signed by licensed nurse or healthcare provider),
immunity by laboratory results (positive titre), or natural disease history (diagnosed, documented, and
signed by licensed healthcare provider) of rubella (German measles), rubeola (measles), and
varicella (chicken pox) within 24 hours of request by hospital personnel.
Volunteering and/or Job Shadowing may include observing patients in a healthcare setting and
observing medical, laboratory, and/or business procedures. I further understand that KentuckyOne
Health offers medical services for the care and treatment of a wide range of illnesses, diseases and
injuries, including but not limited to, such infectious diseases as tuberculosis, hepatitis, and HIV and
that there is a risk, however slight, that my son/daughter might be inadvertently exposed to such
diseases at the Hospital.
I do hereby release KentuckyOne Health, their staff and sponsors from any responsibilities of injury or
accident as a result of the volunteering/shadowing experience. Any medical expenses incurred as a
result of injury or accident will be my responsibility.
I understand that in case of a medical emergency, every attempt will be made to contact me before
medical action is taken. However, this document is my consent as parent or guardian for emergency
treatment and/or procedures necessary for my son/daughter by the professional staff at KentuckyOne
I release, discharge and relieve KentuckyOne Health from any and all claims whatsoever of any
nature as a result of his/her volunteering/shadowing and all related activities.
___________________________________________________ Date_________________________
Parent/Guardian Signature


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