Pleasant Valley Pathfinder Club — PERMISSION & MEDICAL CONSENT FORM

PERMISSION & MEDICAL CONSENT FORM
Name
Address
Age
MaleFemale
Birth Date

MonthDayYear
Date
Phone
Format: (000) 000-0000.
City
Club
State
Parent/Legal Guardian's Name (Father)
Parent/Legal Guardian's Name (Mother)
Grade in school
Zip Code
Event Participation | I understand that I am required to give my consent before my child can participate in this event. By signing this form, I hereby represent that I am the custodial parent or legal guardian of the child listed below and that I consent to my child's participation in this event, including transportation to and from the event (if applicable
Event
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Event Location
Medical Permission: I also give permission for adult leaders/volunteers to administer emergency treatment, contact emergency personnel, and act in my stead in approving necessary medical care until I can reasonably be contacted. I understand that should any medical bills be incurred, our family's insurance(s) will be primary and the Oregon Conference general liability insurance (Risk Management) will be secondary, up to a maximum of $5,000 for one year from the injury date.
Family Insurance Company
Family Insurance Policy Number
Allergies: Please list all allergies your child has:
Medications: Please list all medications your child takes:
Physical Conditions Please list any conditions that limit your childs participation in this event
Please list any dietary requirements and/or allergies that must be observed
I, on behalf of myself, my spouse, next of kin, executors, heirs, assigns, or anyone else who might claim or sue on my or my child's behalf, fully release and agree not to sue the Oregon Conference of Seventh-day Adventists and any of its agents, employees, and/or volunteers from any and all liability, including but not limited to any claims, losses, or liabilities due to death, personal injury, disability, property damage, medical expenses, and/or theft, that may arise from or relate to my child's participation in the event, including transportation to and from the event and any provision of medical care.
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
ParentGuardian Name Please Print
(Cell or Day Phone)
Format: (000) 000-0000.
(Nighttime Phone)
Format: (000) 000-0000.
Should be Empty: