Parent / Guardian
Permission & Liability Release

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

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.

• 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.
• Technology & Connectivity: I understand that volunteer activities may use consumer devices and internet-based platforms that can experience outages, compatibility limits, or other interruptions. Volunteers must follow GCCS setup, privacy, and escalation procedures and may not bypass device, account, facility, or network safeguards.

I understand that volunteer participation may involve ordinary risks associated with entering and moving through community facilities, using consumer technology, interacting with other people, and exposure to communicable illness. To the fullest extent permitted by law, I assume such ordinary risks on my own behalf and release only claims that I am legally authorized to release. Nothing in this agreement purports to waive the minor’s nonwaivable rights or liability arising from gross negligence, reckless or willful misconduct, intentional acts, or violation of law.

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.

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 represent and warrant that I am the student’s legally authorized parent or guardian, that the information provided is true and complete to the best of my knowledge, and that I have read, understood, and agreed to all terms above.