• Member Information

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  • Parent/Guardian Contact Information

  • Parent/Guardian #1

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  • Parent/Guardian #2

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  • Emergency Contact Information

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  • Member Medical Information:

  • IN CASE OF EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME. IN THE EVENT THAT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE HOSPITAL AND ATTENDING PHYSICIAN SELECTED BY BLESSEDGIRL. TO TAKE ANY NECESSARY ACTION, INCLUDING SURGERY, ANESTHESIA, OR INJECTIONS, THAT IS IN THE BEST INTEREST OF MY CHILD.

  • MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGE CHILD CARE

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  • As a parent/guardian of the above participating child, I certify that he/she is in good physical health, has no special needs, and may participating in all of the activities of the BLESSEDGIRL program, except as noted above.

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  • Photo Waiver Release

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  • I hereby affirm that such release to the releasee does not constitute any form of compensation, including royalties arising from the photographs, to my benefit.


    I understand and agree that photographs or videos in the possession of the releasee shall become the property of the releasee. The use and publication of the photographs however, shall conform to my rights as a subject of said photographs.


    I hereby waive my right to inspect of approve the photographs or videos by which my likeness appears.


    I hereby hold harmless, release, and forever discharge BlessedGirl from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

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