In consideration for allowing the student named above (the “Student”) to participate in activities organized by Passion for Life, Inc., a Georgia nonprofit corporation (“P4L”), as parent of guardian of the Student, I authorize P4L and its employees, directors, officers, agents and volunteers (collectively the “Released Parties”) to act on my behalf in providing first aid and in securing any medical care for the Student, including anesthesia, surgery or other necessary medical treatment, in the event of injury, illness or other emergency situation that may arise in connection with P4L activities. I understand that I will be responsible for any medical costs that may arise in securing medical care for the Student. I covenant not to sue and hereby release, discharge, defend and hold harmless the Released Parties from any claim, demand or cause of action whatsoever arising out of or relating to any first aid or medical treatment rendered in connection with the Student’s participation with P4L.
Medical Insurance Provider *
Policy# *
Phone Number
Mailing Address( Street, City, State, Zip)
Name Of Policy Holder *
Phone Number
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