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YOUTH VOLUNTEER SERVICE AGREEMENT

PARENTAL / GUARDIAN CONSENT

State Form 54549 (R2 / 2-15)

INDIANA DEPARTMENT OF NATURAL RESOURCES

AGREEMENT / CONSENT

It is mutually agreed that the below named individual(s) will assist and work with the Department of Natural Resources during a period

of time beginning on or about ________________________, ____________.

(Month and day)

(Year)

I agree and permit my son/daughter to participate as a volunteer for the State of Indiana at __________________________________.

(Name of property and/or event)

I understand I may be held accountable for my son’s/daughter’s actions while he/she is volunteering. I understand that there are

certain risks inherent to participation in this program; including, but not limited to, exposure to insects and other wildlife, poisonous or

prickly plants, temperature and weather changes, uneven terrain, etc. Upon submitting this form, my child(ren) and I assume any and

all risks associated with participation in this program and understand that my child(ren) will receive no payments or remuneration for

said volunteer work and that my child(ren) and I are exempt from the minimum wage and maximum hour working provisions of the Fair

Labor Standard Acts. I further understand that if my child(ren) or I are injured while working for the State of Indiana as a volunteer,

Worker’s Compensation will be the sole and exclusive remedy for any such injury. I certify that to the best of my knowledge my

child(ren) is/are free of any health problems which would endanger him/her while participating in this program.

I understand and acknowledge that the Department of Natural Resources relies on the accuracy of the information submitted on this

Consent form. By providing or completing the information below, I certify that such information is true. I further understand and

acknowledge that any falsifications or misrepresentations may result in termination of the Consent by the Department of Natural

Resources and that anyone making such falsifications or misrepresentations may be subject to criminal penalty.

Printed name of child

Age of child

Checking box indicates parent / guardian agrees to consent form.

Signature or typed name of parent / guardian (Signature required for each child)

Date signed (month, day, year)

Printed name of parent / guardian

Daytime telephone number

(

)

Address (number and street, city, state, and ZIP code)

Printed name of child

Age of child

Checking box indicates parent / guardian agrees to consent form.

Signature or typed name of parent / guardian (Signature required for each child)

Date signed (month, day, year)

Printed name of parent / guardian

Daytime telephone number

(

)

Address (number and street, city, state, and ZIP code)

Printed name of child

Age of child

Checking box indicates parent / guardian agrees to consent form.

Signature or typed name of parent / guardian (Signature required for each child)

Date signed (month, day, year)

Printed name of parent / guardian

Daytime telephone number

(

)

Address (number and street, city, state, and ZIP code)

(More on back if needed)

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Youth Volunteer Service Agreement

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