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MOM-n-PA 2019

MOM-n-PA 2019 Parent/Guardian Waiver for Volunteers under 18

Volunteers under the age of 18 are required to provide a signed waiver that includes the signature of a parent or guardian.

Volunteers age 16-17 as of June 7, 2019: We will accept a limited number of volunteers between the ages of 16-17. A waiver signed by a parent or guardian is required. Volunteers age 16-17 can only be assigned to a NON-clinical area approved by the MOM-n-PA staff. Volunteers under the age of 18 cannot work on the clinic floor.

Volunteers age 16-17 do not have to have a parent/guardian on site, but we must have a signed waiver on file before those volunteers can be allowed to work at MOM-n-PA.

After this Waiver is printed, filled out, and signed, it may be scanned and sent as a PDF file to volchair@MOM-n-PA.com. Or it may be mailed to Dr. Ronald Heier at 1405 Allan Lane, West Chester, PA 19380.


Under-age Volunteer’s Name: ___________________________­­­_________________

Under-age Volunteer’s Address: ___________________________­­­_______________

Under-Age Volunteer birth date, including year:  (mm/dd/yyyy) __________________      
Age of Volunteer on June 7, 2019: ____. 

__ I grant permission for this under-age volunteer to work at MOM-n-PA 2019 and accept full responsibility for this volunteer’s actions.

__ I am the adult parent or guardian of the under-age volunteer named above.

Adult Parent or Guardian Name (print): __________________________________

Adult Parent or Guardian Signature: ____________________________________

Adult Parent or Guardian Phone #s: ____________________________________

Adult Parent or Guardian Email: _______________________________________   
 

Date Signed: ________________________

Please print, fill out, sign, & return this waiver to us in one of these 2 ways:
  • MOM-m-PA email: volchair@MOM-n-PA.com (scan signed waiver & attach as a PDF
  • Dr. Heier’s office address: 1405 Allan Lane, West Chester, PA 19380
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To return to the registration page, click the top tab above (VOLUNTEER REGISTRATION PAGE).