Student Summer Service Club

2014 Teen Summer Service Club Application

Please Download, Fill Out and Print

Student Name: Today’s Date:

Student email address:

Home address:

City: State: Zip:

Home Telephone: Cell phone:

Name of school you will be attending in the fall:

Grade Level:

T-Shirt Size: SmMedLargeXL XXL

Gender: Female MaleDOB:Age:

Primary Adult Contact

Name:Email:

Mailing Address: (If Different from Above)

City: State Zip:

Cell phone number: Work Number:

What is the best way to reach the adult contact?

Cell phone Email Work

Emergency Contact

Name:Phone:

All youth must register and attend one mandatory orientation scheduled for:

Saturday, June 7 from 10:00 a.m.-Noon

3015 Richmond, Suite 100

Houston, TX 77098

Thursday, June 12 from 10 a.m.-Noon

3015 Richmond, Suite 100

Houston, TX 77098

I plan to attend the orientation on June 7

I plan to attend the orientation on June 12

Membership Dues are $40 per registered youth. For your convenience, you can pay securely online from our website. Please visit and select “Make a Donation”. In the “Note” section, please put “Summer Service Club” and your child’s name. If choosing this method of payment, you can Email your completed application to .

If you prefer to mail your application and payment please make checks payable to Volunteer Houston. Please reference Summer Service Club and your child’s name on the check. You may also pay by credit card by including the following information:

Credit Card Number:

Expiration Date:

CVV Code:

Type of card (Visa, Amex, etc.)

Name on Card: Youth I am Paying For:

Billing Address on Card:

City, State, Zip Code:

Amount Charged:

Signature:

______

Application and payment may be mailed to:

Volunteer Houston 3015 Richmond Avenue, Suite 100

Houston, Texas 77098 Phone 713-713-965-0031

Attn: Summer Service Club

SUMMER SERVICE CLUB

WAIVER

I acknowledge that the below-named youth has/have my consent and permission to participate in Volunteer Houston activities and that we/they will be participating at our/their own risk and I hereby agree to release, discharge, indemnify and hold harmless Volunteer Houston and its affiliate organizations, agents, affiliates, employees, staff and sponsors from any and all claims and liability for any and all expenses, personal injury, loss or damages incurred or caused directly or indirectly to us/them during or in connection with or arising out of our/their participation. I understand that we/they are volunteers for Volunteer Houston and will not receive any payment for our/their services. I grant full permission to use photographs, portraits, films and video of me and my children, and quotations made by me or my children to Volunteer Houston and its agents, affiliates and sponsors in materials including television, radio, films, newspapers, online, magazines and other media, and in any form not heretofore described and in accounts of volunteering by or about Volunteer Houston and its programs.

Please Download, Fill Out, Print, Sign and Return with Application:

Youth Volunteer Name:

Parent/Guardian(s) Name:

Parent/Guardian Signature:

Date:______