MEDICAL/ LIABILITY AND PHOTO RELEASE FORM

MEDICAL/ LIABILITY AND PHOTO RELEASE FORM
I hereby give permission for any necessary and reasonable medical attention to be administered to my child/ children who are enrolled with Homeschool ETC in the event of accident, injury, or sickness, until such time as I may be contacted. This permission is effective for the period of one year from the date given below.

In addition, I release Homeschool ETC from any claims or responsibilities for injuries suffered during this program.
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
Child's Name

First NameLast Name
Does your child have any health problems, allergies, or other conditions we should know about?
First Emergency Contact:
Phone
Format: (000) 000-0000.
Second Emergency Contact
Phone
Format: (000) 000-0000.
In an emergency when the parent/guardian or the emergency contacts cannot be reached, a representative of Homeschool ETC may act on my behalf.
Signature
DATE

MonthDayYear
Date
Insurance Company
Insurance Company Policy Number
Policy Number
Member Number
Homeschool ETC produces a slide show to be displayed at our end of semester performance. Does HSE have permission to use your child's photo in this slideshow? You understand that no fee, royalty, or other compensation shall become payable by such use.
Homeschool ETC produces a yearbook at the end of the year. This yearbook is available for purchase by our member families only. Does HSE have permission to use your child's photo in this yearbook? You understand that no fee, royalty, or other compensation shall become payable by such use.
Homeschool ETC maintains a website where we post photos of our classes and activities. Does HSE have permission to use your child's photo on our website? You understand that no fee, royalty, or other compensation shall become payable by such use. *For those students enrolled in the Jr/Sr theater performance, photo permission is automatically granted as a condition of participation.
We would like to send communications about events open to Jr/Sr High students directly to the students. The parents, of course, would be included on all communcations. If you would like your Jr/Sr High student to receive these emails in their own inbox, please provide their email address here.
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