NSBE Jr. of Southern California Permission Slip & Medical Form 2018-19SY
The following permission slip is for all NSBE Jr. events and activities for the 2018-19SY and should be completed AFTER annual membership registration has been completed. THIS IS NOT THE MEMBERSHIP REGISTRATION FORM.
Email Address *
Your answer
Student's Name *
Your answer
Student's Grade in 2018-19SY
Student's School (please include school district if applicable)
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Address
Your answer
Parent/Guardian Cell Phone Number *
Your answer
Parent/Guardian Home Phone Number
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Address
Your answer
Emergency Contact Cell Phone Number *
Your answer
Does your student have any allergies? *
If so, please list them below.
Your answer
Does your student have any ongoing medical or psychological conditions that should concern us? * *
If so, please list them below.
Your answer
Is your student currently taking any medications? *
If so, please list them below.
Your answer
Is your student covered by medical insurance? *
If so, please list your insurance provider and account number.
Your answer
ACKNOWLEDGE STATEMENT
I understand that neither NSBE Jr. of Southern California nor SSG will not be responsible or be able to provide any medical care for my child/ward. I further understand that NSBE Jr. of Southern California will try to aid my child/ward in getting any medical attention needed in the case of an emergency and that the chapter chaperone will take responsibility for any emergency decision making that is necessary. I understand that I will be immediately contacted in the case of such emergency, however my child will be treated as best as possible until I or any other authorized emergency contacts have been contacted.

I am the parent, one of the parents or guardian with whom the above child/ward resides and have legal custody. I assume all risks associated with participation in this event. I, or myself and anyone entitled to act on my behalf, waive and release NSBE Jr. of Southern California, SSG, their agents, employees, chaperones, representatives and successors from all claims or liabilities of any kind arising out or of my child/ward's participation in this event.

In addition, I grant permission to all of the foregoing to use my child/ward or my photographs, motion pictures, recordings, or any other record of this event for any related purpose.

*
Required
Please confirm your acknowledgement of the statement above with your full name and date *
Your answer
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