Parental Consent Form for Minor Volunteers*

I, ___________________________________________________, being the parent/ legal guardian of

______________________________________ (the “Minor”), with date of birth: _______________,

hereby consent to and authorize the Minor to act as a volunteer at Rachel House. I acknowledge and
agree that activities performed by the Minor as a volunteer will be performed strictly on a voluntary
basis, without any pay, compensation, or benefits.

I am fully aware that involvement of the Minor will help children living with serious and terminal
illnesses, including cancer and HIV/AIDS. I accept and agree that the Minor may accompany (under
supervision) our nurses or community health workers to visit the homes of Rachel House patients or
other locations together with Rachel House staff.

I have provided my contact details below and undertake to inform the HR Manager of Rachel House
of any changes to this information. I confirm that all details here are correct.

Name: _________________________________________

Signature ______________________________________ Date: ____________________________

Contact Details

Parent’s/Legal Guardian’s Mobile Phone No. ________________________________

Emergency Contact No. (1) ________________________________

Emergency Contact No. (2) ________________________________

Please also include all medical details that might be relevant in dealing in with your
child in a safe manner, such as allergies, medication, special needs, etc.

*under the age of 18

“We are not here to add days to the children’s lives, but to add life to their remaining days.”

Graha Indramas, K S Tubun Raya No. 77, Slipi, Jakarta 11410, Indonesia
T: +6221 5365 2197 | F: +6221 5365 2198 | www.rachel-house.org