Youth Participant and/or Volunteer Waiver & Release for Minors
Full Name of Primary Guardian
*
First Name
Last Name
Primary Guardian's Phone Number
*
Format: (000) 000-0000.
Emergency Contact's Relationship To Minor (e.g. Mother, Friend, etc.)
*
Primary Guardian's Address
*
Street Address
Apt, Ste, Unit, etc.
City
State
Zip Code
Emergency Contact other than the Primary Guardian
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Full Name of Minor
*
First Name
Last Name
Does the minor have their own phone number?
*
Yes
No
Minor's Phone Number
*
Format: (000) 000-0000.
Does the minor have a different address as the primary guardian?
*
Yes
No
Minor's Address
*
Street Address
Apt, Ste, Unit, etc.
City
State
Zip Code
Does the minor speak any additional languages? If so, please indicate below or type N/A.
*
Does the minor identify as a Peer or Family member?
*
Peer (I am going through mental health struggles; can be undiagnosed or diagnosed)
Family Member (I have a loved one that is going through mental health struggles; can be undiagnosed or diagnosed)
I identify as both a Peer and Family Member
I don't identify as either
View the volunteer opportunities listed below:
What family program(s) from the above list interest you?
NAMI Family-to-Family (F2F)
NAMI Homefront (HF)
Family Support Groups (FSG)
NAMI Family & Friends (F&F)
What peer program(s) from the above list interest you?
NAMI Peer-to-Peer (P2P)
Connection Recovery Support Groups (CSG)
Peer Recovery Support Specialist (PRSS)
NAMI In Our Own Voice (IOOV)
What peer program(s) from the above list interest you?
NAMI Basics
NAMI On Campus
Youth Peer Recovery Support Specialists (Y-PRSS)
NAMI Ending the Silence (ETS)
What wellness program(s)from the above list interest you?
Wellness Activities (yoga, vision boarding, art, etc.)
Hearts + Minds
Mental Health Presentations
What advocacy & outreach program(s)from the above list interest you?
NAMI FaithNet
NAMI Provider
NAMI Smarts
Sharing Hope
Compartiendo Esperanza
Hearing Voices Simulation
What crisis intervention training program(s)from the above list interest you?
Crisis Intervention Team (CIT)
Sharing Your Story with Law Enforcement
What general programs & further community outreach program(s)from the above list interest you?
Community Events Representatives
Community Outreach Resources Team
Office Volunteers
Outreach Volunteer
Special Events Volunteers
Special Populations (SP) Engagement Team
Social Media Team
NAMIWalks
Agreements & Disclaimers
Volunteer Expectations/Agreement Form Signature
*
Confidentiality Form Signature
*
Sexual Harassment Policy Form Signature
*
Photo Release Form Signature
*
Your Copy of the Volunteer Handbook
Volunteer Handbook Acknowledgement
*
I hereby advise that the above-named minor has the following allergies, medication reactions, or unusual physical conditions, which should be made known to a treating physician (If none, please write N/A).
*
By completing this form, the minor and guardian acknowledge that this approval applies to all NAMI Southern Nevada events.
*
Understood, I agree.
I, the undersigned, as the parent or legal guardian of the minor named, acknowledge and understand that participation in activities organized by NAMI Southern Nevada may involve risks, including the risk of serious injury or death. By signing this document, I agree to release, indemnify, and hold harmless NAMI Southern Nevada, its officers, directors, employees, agents, volunteers, and any person transporting the minor to or from agency activities (collectively referred to as "the Organization") from any and all claims, demands, actions, or causes of action arising out of or related to the minor’s participation in said activities. I confirm that the minor meets the minimum age requirement of 15 years and grant permission for their participation in activities both at the NAMI Southern Nevada office and at any off-site events organized by the Organization.I certify that, to the best of my knowledge, the minor is in good health and capable of participating in these activities. In the event of illness or injury, I authorize the Organization to seek and administer emergency medical treatment as deemed necessary and understand that I will be responsible for any associated costs. I also grant permission for NAMI Southern Nevada to use any photographs or videos taken during activities for publicity purposes.I further consent to the minor being added to the Constant Contact emailing platform for the purpose of receiving emails about volunteer opportunities hosted by NAMI Southern Nevada. This waiver shall be binding upon me, my heirs, executors, and administrators.
*
I understand and acknowledge the information above.
Minor's Signature
*
Minor's Printed Name
*
Date
*
-
Month
-
Day
Year
Guardian's Signature
*
Guardian's Printed Name
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: