BLM 5280 Freedom School Parent/Guardian Liability Release
Parental Permission, Liability, Medical, and Media Release for child(ren) participating in BLM 5280 Freedom School.
Email address *
Child's First and Last Name *
If registering more than one child as a participant (entering Kindergarten through 5th grade), fill out a separate form for each child.
Your answer
Child's Age *
Your answer
Child's Grade (entering) *
Your answer
Home Street Address, City, State Zip *
Your answer
Best Phone Number *
Your answer
Consent for Participation *
I give consent for my child to participate in the BLM Freedom School, hosted by BLM 5280. I understand and agree that my child will follow the instructions of any adult leader. If my child cannot adhere to the rules at the Freedom School, or if they become upset and need to leave, I (or an authorized individual specified below) agree to pick them up, even if it’s shortly after being dropped off. If you consent, type your initials below.
Your answer
Known Allergies or Medical Conditions/Needs *
Your answer
Medical Emergency/Liability Release & Consent for Medical Treatment for a minor *
If I cannot be reached, the leaders involved with BLM's Freedom School are designated to act on my behalf. I give permission for any and all medical attention to be administered to my child in the event of accident, injury, sickness, etc., under the direction of a duly licensed Doctor of Medicine or Doctor of Dentistry until such time that I may be contacted. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child. I agree that I will not hold BLM 5280 or any paid or volunteer staff liable for any accident, injury, illness, etc. the child may incur during the time in their care. If you consent, type your initials below.
Your answer
Health Insurance Company *
Your answer
Policy Number *
Your answer
Physician/ Doctor's Name *
Your answer
Physician/ Doctor's Phone *
Your answer
Physician/ Doctor's Address, State, Zip *
Your answer
If I am unable to pick-up at 12:30 pm, the following individual(s) have permission to pick-up my child*. Include first/last name, and phone number. (example: Jamal Smith 333-333-3333) * *
*At pick up, this person MUST present state identification (Driver's license etc) for the child to be released.
Your answer
Multi-Media Release for a minor *
I agree to allow BLM 5280 to use any multimedia with my child (including pictures, video, and the like) at their discretion for the purpose of promoting this school. However, your child’s name will not be displayed.
Required
Parents, type full legal name below: *
Your answer
Electronic Signature *
Required
Date *
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A copy of your responses will be emailed to the address you provided.
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