Permission to Participate

Permission to Participate

Form Instructions: This form is to be filled out completely before the student is allowed to participate in the New Mexico MLK Jr. Commission 2023 Youth Leadership Conference.
Student Name*

First NameLast Name
School Name*
Middle/Highschool Name
The parent/guardian of (type in student name here) * gives permission, indicated by signature at the bottom of the page, for this student to participate in the activity described below.
Youth Leadership Conference June 2-4, 2023

Location : Courtyard by Marriot Las Cruces at NMSU 456 E. University Ave. Las Cruces, NM 88005 at New Mexico State University.
Transportation by :*

BusPersonal AutomobileOther
All Youth are expected to display the virtues of respect, citizenship, caring, trustworthiness, fairness, and responsibility. These are the six pillars of the “Character Council". All students who are participating in the NMMLKJRC Youth Leadership Conference 2023 are expected to practice these qualities throughout the entire trip.

Participation is a privilege offered to, and earned by, youth. Youth engaged in these activities are serving as representatives of their school and community and are expected to always maintain the highest standards of behavior.

By signature below, the parent/guardian hereby authorizes emergency medical treatment and/or hospitalization deemed necessary by emergency response or medical personnel.

IF YOUR CHILD HAS SPECIAL MEDICAL NEEDS OR ROUTINELY MUST TAKE MEDICATION YOU MUST COMPLETE THE LAST PORTION OF THIS FORM.
Emergency Contact Information

Required**
Students Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent home/cell No. *
Please enter a valid phone number.
Parent Work No.
Please enter a valid phone number.
Other Emergency Contact Information:*

First NameLast Name
Relationship to Student*
Phone Number*
Please enter a valid phone number.
Medication Student is taking :
Known allergies to medications or foods:
Medical services for ill or injured students, or students who routinely must take medications or who have medical concerns that may require treatment, while participating in the NMMLKJRC Youth Leadership Conference

New Mexico Martin Luther King Jr. State Commission wishes to avoid difficulties in obtaining medical services for students who may become ill or injured during sponsored activities.

As the parent/guardian of a student participating in Youth Leadership conference, it is necessary that you consent in advance, to medical attention for your child. You must provide direction if no consent is given.

In the event of illness or injury, a reasonable effort will be made to contact you to obtain consent in advance of medical services being given. If we are unable to contact you, the MLK Jr State Committee sponsor will consent to such services for your child by acting on your behalf based on written advance authorization. That authorization is in the consent form below.

Selection of a doctor or hospital will be made on the basis of family preference, if known. If family preference is unknown, the student will be taken to the closest hospital or one consistent with the existing circumstances.
Authorization for Medical Services
l, the parent/guardian of,(STUDENT NAME)*, have read the above and hereby designate the New Mexico Martin Luther King Jr. State Commission to act in my behalf in the event of a medical emergency. He/she may authorize such hospitalization, medical attention, and surgery as may be required in an emergency because of illness or injuries sustained by my child while participating in the Youth Leadership Conference. I hereby assume financial responsibility for hospitalization, medical attention, and surgery provided.
1. List medical concerns (including allergies) which sponsor and chaperones need to be aware of:
2. Prescription medications, for which an authorization form to be taken at school has been filled out, that need to be taken by or administered to student while participating in the Youth Leadership Conference :
3. Prescription medications, for which an authorization form will need to be taken to the Youth Leadership Conference has been filled out, that need to be taken by or administered to student in an emergency:
Parent Signature*

Clear
Student Signature*

Clear
Parent/Student Date Signed:*

MonthDayYear
Date
Instructions If Limited or No Medical Services are Authorized:

IF PARTICIPATION IN FIELD OR ACTIVITY TRIP IS PERMITTED BUT MEDICAL SERVICES ARE NOT AUTHORIZED, PLEASE ATTACH A WRITTEN STATEMENT OF PROCEDURES

TO BE FOLLOWED IF YOUR CHILD IS INJURED OR ILL DURING THE TRIP.

THIS FORM MUST BE IN THE POSSESSION OF THE SPONSOR AT ALL TIMES DURING ALL TRIPS.
Should be Empty:

Permission to Participate

Emergency Contact Information