Parental Consent for Minor Participant can be printed from HERE and
mail to Rebuilding Together North Jersey’s office at PO Box 1389, Ridgewood NJ 07451-1389.
Also, you may complete our online application:
Parental Consent for Minor Participant
Name of Child:

The above named child has my permission to participate in the Rebuilding Together North Jersey, Inc., home repair project
currently scheduled for (date)

*(Your Last, First name).

On behalf of such child, I have signed a Volunteer's Agreement and Release From Liability and hereby agree to all of the terms and conditions of the Release.

In case of medical or dental emergency, I understand that every effort will be made to contact me at the telephone number set forth below. If I cannot be reached, I hereby give permission to the physician or dentist selected by Rebuilding Together North Jersey, Inc. to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for the child named above. A copy of this permission form may be accepted by and treated by the physician as equivalent to the original permission form.

Date:
Signature of Parent or Guardian:
Telephone:
Email: *


Please complete the following:

Medical Insurance Carrier:
Policy Number:
Family Doctor :
Address:
Telephone:
Family Dentist:
Address:
Telephone:


ANY DRUG OR FOOD ALLERGIES:

LIMITATIONS ON ACTIVITIES:
IF I CANNOT BE REACHED, PLEASE CONTACT:
TELEPHONE:

Signature of Parent or Guardian:     Date:


Rebuilding Together North Jersey, Inc.
P.O. Box 1389, Ridgewood, NJ 07451-1389 (201) 447-8886