CONSENT FOR MINOR TO PARTICIPATE IN VOLUNTEER ACTIVITIES

I hereby authorize and consent for , a minor, to participate in such volunteer activities at Pikeville Medical Center (hereinafter “PMC”) from time to time as may be directed by the Hospital’s Director of Volunteer Services or their designated representative. I understand that volunteer services are donated to PMC without compensation or promise of future employment, and are donated for humanitarian, religious, charitable, or other altruistic reasons.

I hereby further release and hold harmless PMC and its officers, agents, directors, and employees from any and all claims of liability for any damages, injury or illness resulting to the aforementioned minor while participating in such volunteer activities.

I hereby authorize and confer consent to PMC to render any and all medical treatment and care to that is deemed advisable by, and is to be rendered under the general or direct supervision of any physicians and/or surgeon on the PMC medical staff, whether or not such care is to be rendered in the physician’s office or at PMC. This authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority to PMC to allow any and all such diagnosis, treatment, or hospital care which said physician, in the exercise of independent medical judgement, may deem advisable.

I hereby agree that will comply with PMC’s vaccination policy, including any authorizations to release his/her protected health information or otherwise apply for an appropriate exemption, and that failure to comply with PMC’s vaccinations policy may prevent from being accepted as a volunteer, or may lead to his/her dismissal as a volunteer.