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JUNIOR HIGH MINISTRY ACTIVITY CARD

I represent that I am the parent or legal guardian of the minor participant identi ed below (hereafter “my child”). By signing this release, I hereby warrant that I have the legal right, without limitation, to enroll my child into the activities of Calvary Chapel Costa Mesa Junior High Ministiry. By placing my signature below, I hereby grant my permission to allow my child to participate in the activity without restriction or limitation.

In consideration of Calvary Chapel Costa Mesa Inc.’s agreement to permit my child participate in the activity, the receipt and su ciency of which consideration is hereby acknowledged, I, individually, and on behalf of my child and our respective heirs, successors, assigns and personal representatives, agree as follows:

(I) GENERAL LIABILITY RELEASE AND INDEMNIFICATION

I nonetheless authorize my child to participate in the activity and I agree that my child assumes any and all risks of injury or harm, of any kind, that may be sustained by my child while traveling to, from, or participating in the activity. To the fullest extent permitted by law, I fully release and discharge Calvary Chapel Costa Mesa Inc., its representatives, a liates, subsidiaries, divisions, members, directors, o cers, employees, agents, servants, volunteers, sta , speakers, teachers, or any of them (collectively referred to herein as “Calvary Chapel”), from all actions, suits, claims, causes of action, and demands for any injury or harm of any kind whatsoever which may arise from or out of my child’s travel to, from, or participation in the activity, however such injury or harm is caused, even if it is caused in whole or in part by action, inaction, or negligence of Calvary Chapel. This release is intended to discharge Calvary Chapel against any and all liability arising out of or connected in any way with my child’s travel to, from, or participation in the activity, even though that liability may arise out of the negligence or carelessness on the part of Calvary Chapel.

Should any claim be made or any lawsuit be led against Calvary Chapel on account of any injury or damage to my child arising from any or related in any way related to my child’s travel to, from, or participation in the activity, I agree to defend, save, hold harmless, and to fully and completely indemnify Calvary Chapel for any and all amounts incurred, whether by settlement or judgment, including any amounts incurred by Calvary Chapel in defending against any such claim or judgment, including all attorney’s fees and costs incurred. Moreover, should any claim be made or any lawsuit be led against Calvary Chapel by any third party on account of the acts or conduct of my child arising from any or related in any way related to my child’s travel to, from, or participation in the activity. I further agree to defend, save, hold harmless, and to fully and completely indemnify Calvary Chapel from any and all amounts incurred, whether by settlement or judgment, as well as any amounts incurred by Calvary Chapel for defending against any such claim or judgment, including all attorney’s fees and costs incurred.

This general liability release and indemnity agreement shall apply to all known, unknown and/or unanticipated injuries and damages resulting from or during my child’s travel to, from, or participation in the activity from any cause whatsoever.

(II) AUTHORIZATION AND CONSENT TO MEDICAL TREATMENT

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of the following.

I authorize Calvary Chapel to arrange for or provide any necessary transportation for my child to the nearest medical facility for urgent or emergency medical treatment, if indicated, and I assume all responsibility for payment for such treatment. I acknowledge that my child has his or her own medical and dental insurance and I fully and unconditionally release and indemnify Calvary Chapel from all liability for any medical or dental treatment rendered to my child.

I hereby authorize and consent for my child to receive medical treatment, including any x-ray, examination, anesthetic, medical or surgical procedures which may be deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state or country in which such medical treatment occurs. I understand that this authorization is given in advance of any speci c diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care to my child to which the aforementioned licensed medical professional or institution which, in the exercise of their best judgment, may deem advisable. I understand that every e ort shall be made to contact me prior to rendering any medical treatment to my child, but that any of the above treatment will not be withheld if I cannot be reached. This authorization is given pursuant to the California Family Code section 6910, and similar provisions of the laws of the State or Country in which the medical or dental care is being sought.

I hereby authorize any hospital, medical facility, other medical provider who has provided treatment to my child to surrender physical custody of my child to Calvary Chapel upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California, and similar provisions of the laws of the State or Country in which the medical treatment has been provided.

These authorizations concerning medical treatment given to my child shall remain e ective through the dates set forth above for the activity, unless sooner revoked in writing.

(III) VIDEO/PHOTO RELEASE

During the activity, photographs, audio recordings, and videos may be taken by Calvary Chapel and used for future publicity. I give permission for such photographs, audio recordings, and videos depicting my child captured during the activity to be used for the purposes of Calvary Chapel, including in promotional materials and publications and I waive any rights of compensation or ownership thereto. I understand I will not be paid royalties or other compensation and I forfeit any rights I may have to payment if such photos, videos or recordings are published. I agree that any media depicting my child during his or her participation in the activity is the sole property of Calvary Chapel.

No oral representatives, statements, or inducements have been made by or between the parties to this Agreement with respect to the subject matter of this Agreement apart from the matters set forth within this Agreement.

In signing this Agreement, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it a ects my legal rights and those of my child, that it is a binding Agreement, and that I have signed it knowingly and voluntarily.

THIS IS A RELEASE OF YOUR RIGHTS. READ CAREFULLY BEFORE SIGNING.

Today's Date: August 26, 2019

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 

1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

Child's Regular Physician

Phone Number

MEDICATION INFORMATION 


Medication

Dosage

When Taken

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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