2017-18 Medical Release

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FAMILY MEDICAL AND TRANSPORTATION PERMISSION RELEASE

2017-2018

 

I, the undersigned, represent to SHINE that I am the parent, guardian of the person, or managing conservator of my Child.

I hereby give my Child my express consent to participate in all regular and special SHINE activities.

I hereby further consent to my Child and all participating adults being transported to and from SHINE sponsored activities by authorized and licensed SHINE personnel.

In the event that my Child or participating adult becomes ill or is injured, which illness or injury necessitates medical and/or surgical treatment, in the sole discretion of SHINE personnel I authorize such treatment to be administered under the direction of any licensed physician.  I agree to pay any charges, fees, expenses, and costs associated with such treatment and I hereby indemnify and hold harmless, SHINE, its agents, representatives, trustees, and staff from all such charges, fees expenses, and costs incurred for the treatment of my Child or participating adult.

 

I HAVE READ THE ABOVE MEDICAL AND TRANSPORTION RELEASE AND SIGN IT VOLUNTARILY.  This permission release will remain in effect until our membership is terminated or until I revoke it in writing; whichever comes first.

By typing my name and the names of my family members (both adults and children) below I certify that this will act as our physical signatures and will be binding as such for all purposes.

Please type each family member's name below in the appropriate boxes. Please fill in all requested information completely.

1. *

Date:

2. *

Mother/Guardian Signature:

3. *

Phone Numbers (Home & Cell):

4. *

Address:

5. *

Father/Guardian Signature:

6. *

Phone Numbers (Home & Cell):

7. *

Address:

Emergency Contact Information (not parent)

8. *

Emergency Contact Full Name: 

9. *

Emergency Contact Phone Number(s): 

10. *

Child's Name:

11. *

Child's Allergies (food or medication): 

12. *

Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

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Child's Allergies (food or medication): 

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Child's Current Medications &/or Medical Conditions:

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Child's Name:

38. 

Child's Allergies (food or medication): 

39. 

Child's Current Medications &/or Medical Conditions:

40.

Child's Name:

41. 

Child's Allergies (food or medication): 

42. 

Child's Current Medications &/or Medical Conditions:

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