FORCE Membership Agreement

MEDICAL HISTORY
Emergency Contacts

Parent or Guardian Information
Name*

First NameLast Name
Relationship*
Parent or Guardian
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Name

First NameLast Name
Relationship
Parent or Guardian
Phone Number
Please enter a valid phone number.
Email
example@example.com
Health History

DiabetesAsthmaEpilepsyOther
Allergies

AspirinBee StingPenicillinOther
Any Dietary Restrictions?*
Please enter N/A if none.
Additional Information
Any precautions to observe? Current medications? Any Additional health informration?
I hereby give permission to the Saginaw Community Foundation staff to authorize emergency medical treatment if need be for my child,name*.
Parent or Guardian Signature *

Clear
Date*

MonthDayYear
Date

PERMISSION SLIP
The undersigned FORCE participant and/or the undersigned parent or legal guardian of the participant who is under the age of 18, on behalf of himself or herself or the participant under the age of 18, waive(s), release(s) and agree(s) to hold harmless the Saginaw Community Foundation/FORCE members, its affiliates, representatives, agents, officers, board members, employees and volunteers (“The Releasees”) from any liability to the undersigned and the personal representatives, heirs, assigns, and family of the undersigned.

This waiver and release of liability by the undersigned of event participants applies to the all FORCE events that the undersigned will participate in, for all loss or damages on account of injury or harm to the participant or to the property of the participant whether caused by the negligence of the Releasees or otherwise.

I also give my consent to the aforementioned organizations to use my name, photograph, portrait, and any likeness in any media form and type of publication, including annual reports and newsletters, and grant to the these organizations any and all rights to said use without compensation. I relinquish and give all right, title and interest I may have in the finished pictures, negatives, reproductions, and copies of the original prints and negatives.

INDIVIDUAL AND/OR PARENTAL CONSENT/WAIVER AND RELEASE OF LIABILITY

The undersigned has/have read this Waiver and Release of Liability and has/have voluntarily signed it, representing and warranting that the participant is at least 18 years of age, or, in the alternative, that the undersigned is the participants parent or legal guardian.
Iparent/ guardian * , give permission for my child, child name* to attend/ participate in FORCE events described above and I further agree to all terms of the Waiver & Release of Liability stated herein.
Youth Participant Signature*

Clear
Date*

MonthDayYear
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
If you have any questions, please contact Cecelia Hopkins at (989) 755-0545 or cecelia@saginawfoundation.org
Should be Empty:

MEDICAL HISTORY

Emergency Contacts

PERMISSION SLIP

If you have any questions, please contact Cecelia Hopkins at (989) 755-0545 or cecelia@saginawfoundation.org