Signed this day of , 20 I am with Group or Team Leaders Phone:
Name: Signature
Address City State Zip
Cell Phone in case of emergency E-mail please

PARENTAL CONSENT FORM (minors 12-17)
(Minors MUST return Signed Parental Consent form with their application and bring a 2nd COPY on Workday)

Minor's Full Name (First, Middle, Last)
Minor's Date of Birth
Working with what Group
 Community working in
Minors Cell Phone Number

The above named minor has my permission to participate in the Christmas in Action of Oakland County, Inc. Home Repair Project, hereinafter referred
to as Project, currently scheduled for . On behalf of such minor I have signed a Volunteer's Agreement and Release
from Liability, hereinafter referred to as Release, and hereby agree to all of the terms and conditions of the Release.

In case of medical or dental emergency, I understand that every effort will be made to contact me at the telephone number set forth
below. If I cannot be reached, I hereby give my permission to the physician or dentist selected by Christmas in Action of Oakland
County, Inc. to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for the minor named above. A copy
of this permission form may be accepted by and treated by the physician as equivalent to the original permission order.
Date Print Name of Parent/Guardian
Signature of Parent/Guardian
Telephone Number/Cell Number
Name of Medical Insurance Carrier: Policy Number & Group Number:
Minor's Primary Physician: Telephone:
Primary Physician's Address:
Minor's Dentist/Orthodontist: Telephone:
Dentist/Orthodontist Address:
Any Food or Drug Allergies: Limitations on Activities:
Contact Name
 Cell
 Contact Name
 Cell
Relationship to Minor Relationship to Minor