Hurricane Valley Commonwealth Permission and Medical Release Form
Please complete this permission slip for each activity outside of normal class activities.
Email *
Activity *
Date *
Which class is the event for? *
Name of Participant *
Date of birth
MM
/
DD
/
YYYY
Contact phone number *
Any medical conditions that we need to be aware of? (i.e. special diet, allergies, medication, chronic illness, surgery in the past year, physical conditions that limit activity) *
I give permission for my child/youth to participate in the activity listed above and authorize the adult leaders supervising this activity to administer emergency treatment to the above-named participant for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover this activity and travel to and from this activity. *
Parent signature (Typing your name constitutes a digital signature) *
Submit
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