Christian Home Educators of Tucson Northwest

Rooted in Christ, United in Purpose

Christian Home Educators of Tucson Northwest

Parent-Led. Relationship-Based. Community-Focused.

Christian Home Educators of Tucson Northwest

Fellowship, Activities, and Support All Year Long

Christian Home Educators of Tucson Northwest

Learning and Growing Together

Christian Home Educators of Tucson Northwest

Serving Families Across Northwest Tucson

Emergency Contact Form

indicates a required answer

Insurance and Emergency Contact Form

This form must be completed by all members and guests to participate in any activity

I, the undersigned parent/guardian, do hereby grant permission for my child(ren) listed above to participate in CHET-NW Activities. In order that my child may receive the proper medical treatment in the event that he/she may sustain injury or illness during any CHET-NW activity, I hereby authorize a supervising adult to obtain or provide medical treatment for my son/daughter for such injury or illness during the CHET-NW activity, and I hereby hold CHET-NW, as well as its representatives, harmless in the exercise of this authority. I hereby release from any liability CHET-NW and all adult supervisors and class helpers in the event of any accident en route or during activities. I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my son/daughter for physical illness or injury that he/she may sustain during any CHET-NW activity.

I also understand the P.E. Program includes activities such as running, jumping, stretching, and other physical exertion to benefit the students. Understanding that there is always a possibility that my son/daughter may sustain physical illness or injury, I acknowledge and understand that my son/daughter is assuming the risk of injury or illness by his/her participation, and I further release CHET-NW and its representatives from any claims for personal illness or injury that my son or daughter may sustain during P.E. activities.

I am aware that if my child has a medical condition that prevents or prohibits him/her from participation in any P.E. activity (i.e. running, jumping, stretching) I must notify the P.E. Coach on the day of participation.

I accept these terms.

1. *

Please type your full name in the box below to indicate your acceptance of these terms:

2. 

Spouse's signature. Please type your full name in the box below to indicate your acceptance of these terms:

Insurance Information

3. 

Policy holder's Name:

4. 

Insurance Company Name:

5. 

Policy Number:

Emergency Contact

6. *

List an emergency contact other than a parent or guardian:

7. *

Emergency contact home phone:

8. 

Emergency contact cell phone:

9. *

Emergency contact's relationship to the student:

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