Teen Homeless Simulation Registration and Permission Slip
Must be completed by parent or legal guardian
Parents or Legal Guardians Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Legal Guardian's Phone Number
*
Please enter a valid phone number.
Child's Name
*
First Name
Last Name
Child's Birthdate
*
-
Month
-
Day
Year
Date
I give permission for my child to attend Foundation For Living’s homeless simulation event, at Foundations For Living on August 2, 2024 - August 4, 2024. I further give permission for my child to be transported to and from events by hired and volunteer drivers authorized by Foundations For Living if needed. I also hereby authorize the leaders, volunteers, Foundations For Living, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child. I further authorize the staff of Foundations For Living of Waupaca, Wisconsin to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult.
*
Type Parents Name Here
Medical Insurance Provider
*
Medical Insurance Policy Number
*
Child's Primary Physician
*
Primary Physician Phone Number
*
Parents Signature
Student's Name
*
Student's Signature
Submit
Submit
Should be Empty: