IB Camping Trip 2024

Child's Name (Last)

Child's (First)

Date of Birth

Address

Street Address Line 2

City

Parent(s) or Guardian Information

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Emergency Contact: In the event that the primary guardian cannot be reached.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relation

Medical Information:

Insurance Carrier

Policy No.

Family Doctor (Name)

(Phone)

Format: (000) 000-0000.

Medical facts requiring special attention (Diabetes, Epilepsy, etc)

Allergies

Other Concerns

Medicine #1

List MedicationTime To Administer

Medicine #2

List MedicationTime To Administer

Do you object to our getting medical help for your child?

In the event of an emergency may we take her to the hospital before we call you?

YesNo

PARENT/GUARDIAN: SIGNATURE

Date

2024 Holiday World Child Care Authorization and Permission Form

I, (Parent(s) Name):the parent(s) or guardian(s) of the below described minor, are legally entitled to give this authorization. I/we grant Chrystal Hines IB President, as well as IB Mentors, life-coaches and sponsors, temporary authority limited to the below defined power over the following child:

The powers granted to above Mentors. Life-Coaches and Sponsors are limited to the following: *To seek medical care for the child, including, but not limited to visits to the doctor and/or hospital. To authorize medical treatment or medical procedures in the event of an emergency situation. *To provide food and shelter for the above-named child and to make decisions regarding their day-to-day activities for the selected date range. "To transport said child to and from our scheduled destination.

I/we understand that reasonable precaution will be taken to safeguard my
child’s social and mental well-being during this session (physical activity:
Swimming, Games, Hiking, Amusement Rides, and Tours) as are taken in all
other Inner Beauty sessions. The Camping/ Holiday World Trip will begin
Friday, October 11th, 2024 from the IBNB Center and will conclude Sunday,
October 13th, 2024. If you have any questions pertaining to the trip: please
call Chrystal Hines at 317-833-5810.

I hereby give permission for my child to participate in the 2024 Holiday World Trip as a life-coaching/ mentoring transformational travel activity for The Inner Beauty program, Inc.

I/we will not hold Inner Beauty Program, Inc., New B.O.Y., The Indiana Department of
Child Service, Marion County Juvenile Probation, the Mentors and volunteers, nor
various school districts, liable for any concerns or unfortunate mishaps that may
occur during this mentoring trip. This grant of authority is effective as of
10/11/24, and shall remain in effect until 10/13/24.

Date: This is a legal and binding document in the court of law.

This grant of authority is signed this

2024 in the county of Marion, State of Indiana.