IBNB College Trip 2023

Child's (First)

Child's Name (Last)

Date of Birth

Address

Street Address Line 2

City

Postal / Zip Code

Parent(s) or Guardian Information

Name

First NameLast Name

Phone Number

Work Number

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.

Relation

Medical Information:

Insurance Carrier

Policy No.

Family Doctor (Name)

(Phone)

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

Allergies

Other Concerns

Medicine #1

List MedicationTime To Administer

Medicine #2

List MedicationTime To Administer

Medicine #3

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?

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

YesNo

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

YesNo

PARENT/GUARDIAN: SIGNATURE

Date

2023 HBCU Historical and College Trip 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, physical and mental well-being during all trip activities. (Traveling and Touring) HBCU Historical and College Trip We will depart from the IBNB Center on the New Revelation Campus at 6701 Oaklandon Rd on July 20th & return on July 24th If you have any concerns: Please call CHRYSTAL HINES 317-833-5810 or KAREEM HINES at 317-869-5022.

hereby give permission for my child

to participate in the HBCU Historical and College Trip as a life-coaching/ mentoring transformational travel activity for The Inner Beauty program, Inc & New Breed Of Youth.

I/we will not hold The Inner Beauty program Inc. Chrystal Hines, the life coaches, mentors, sponsors, Various School Districts, Choices INC., Child Advocates, Department of Child Services, The Marion County Juvenile Probation, nor Transportation Services liable for any concerns or unfortunate mishaps that may occur during this mentoring trip. This grant of authority is effective as of 7/20/2023, and shall remain in effect until 7/24/2023.