Permission/Medical Form
EVENT NAME: SHINE YOUTH RALLY
DESTINATION: WEST CATHOLIC HIGH SCHOOL
ACTIVITY SUPERVISOR: STEFANIE IWAN . 616-340-0596
DATE/TIME: SATURDAY, MARCH 24TH 2PM-8:30PM . $25 before 3/23 or $35 cash at the Door
METHOD OF TRANSPORTATION: PARENT
Email address *
Child(ren)'s Name(s) *
Your answer
Parent/Guardian Name(s) *
Your answer
Phone Number During Event *
Your answer
I am available to chaperone
Medical Information *
Please list doctor's name and phone number any allergies, medications or pertinent comments
Your answer
Health Insurance Data *
Company, policy, group and contract
Your answer
Signature *
Please type your name to certify above Statement of Consent
Your answer
Statement of Consent *
I hereby consent to participation by my child(ren) in the event described above. I understand that the event will take place away from the school/parish grounds. I further consent to the conditions stated above on participation in this event, including the method of transportation. In consideration of my child being allowed to participate in this event, I agree to waive and release, and indemnify and hold harmless Immaculate Heart of Mary School/Parish, any and all affiliated organizations, its/their employees, agents, representatives, volunteers and drivers, from any and all claims I or my child may have, excluding claims for intentional misconduct or gross negligence, arising from or relating to my child’s participation in this event. I authorize Immaculate Heart of Mary School/Parish to obtain necessary medical treatment for my child in case of illness, injury or accident. This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. I grant to IHM Parish/School my consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my/my child's name, voice and/or image that arises from participation.
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