Parent / Guardian
Permission & Liability Release

1. Student & Guardian Information

• Student Full Name
• Date of Birth and Age
• Parent / Legal Guardian Name
• Parent / Legal Guardian Phone
• Parent / Legal Guardian Email

2. Volunteer Program Acknowledgment & Consent

I, the undersigned parent or legal guardian of the minor student named above, hereby grant permission for my child to participate as a Student Volunteer with Gulf Coast Connection Services LLC (GCCS). I understand that GCCS provides non-clinical technology assistance, digital connection visits, and companion support for residents in care communities.

3. Safety, Supervision & Boundaries

• Non-Clinical Support: I acknowledge that GCCS services are strictly non-clinical. My child will not administer medical care, assist with physical mobility transfer, or handle confidential Protected Health Information (PHI).
• Conduct & Professionalism: I certify that my child will abide by all facility rules, visitor policies, confidentiality standards, and GCCS protocols at all times.

4. Liability Release & Waiver

I understand and assume all reasonable risks associated with volunteer activities in a community environment. To the fullest extent permitted by law, I release and hold harmless Gulf Coast Connection Services LLC, its officers, facility partners, and employees from any liability, injury, loss, or damage arising out of or related to my child’s participation in the volunteer program, except in cases of gross negligence or intentional misconduct.

5. Photo & Media Release (Optional)

Choose whether you grant GCCS permission to use photographs or video recordings of your child taken during volunteer activities for promotional, website, or social media purposes. Declining media permission does not affect application review.

6. Electronic Signature & Attestation

Electronic Records Consent. I agree to conduct this transaction electronically and to receive this agreement and confirmation in electronic form. I understand that I may print or download a copy for my records and may contact GCCS to request a paper copy.

By typing my name below and submitting this form electronically, I intend my typed name to serve as my electronic signature. I attest under penalty of perjury that I am the legally recognized parent or legal guardian of the student, and that I have read, understood, and agreed to all terms above.