(ADD ON 3) Youth Volunteer (Designed Adult Acknowledgement)

DESIGNATED SUPERVISING ADULT ACKNOWLEDGEMENT

Please note, that a Volunteer Waiver (Adult) must also be completed for the Adult volunteer
MINOR PARTICIPANT(S)
Full Name of Youth/Minor(s):

First NameLast Name
Parent/Legal Guardian Name(s):

First NameLast Name
By signing below, I acknowledge that I have been designated by the parent/legal guardian to supervise the minor(s) identified above during the specified volunteer activity.

I agree to:
- Remain responsible for the minor's supervision during the approved activity;
- Follow FirstPres policies, safety requirements, and staff instructions;
- Maintain appropriate boundaries with the minor;
- Immediately notify the parent/guardian and FirstPres staff of any significant injury, illness, safety concern, or other incident involving the minor; and
- Return responsibility for the minor to the parent/guardian when the approved volunteer activity ends or when the parent/guardian otherwise requests it.
I understand that this designation does not make me a FirstPres employee, agent, or representative.
DESIGNATED SUPERVISING ADULT
Printed Name:

First NameLast Name
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Best Contact Phone:
Format: (000) 000-0000.
Should be Empty:

DESIGNATED SUPERVISING ADULT ACKNOWLEDGEMENT