Permission Form 2025

Permission Effective January Year Start* through December Year End*

IORG Members Name*

First NameLast Name

Date of Birth*

Date

Assembly

In the case of any medical emergency, I, the undersigned, understand that every effort will be made to contact me regarding my daughter’s welfare. In the event that I cannot be reached, I hereby give my permission to authorize emergency medical treatment in the event of illness/injury to my daughter. The health care provider is authorized to perform emergency medical services upon the consent of an adult in charge, from the International Order of the Rainbow for Girls in Connecticut.

I will assume all financial responsibility for the case of my daughter. I herby release the IORG of CT and their designees from any lability involving sickness, hospitalization and/or injury.

Medical Insurance Adult*

First NameLast Name

Insurance Company*

Policy Number*

Primary Care Physician *

Name

Primary Care Physician Phone Number*

Please enter a valid phone number.

Medications / Reason*

Medications/Pain relievers presently taken are. If none, please put None.

Allergies And Reactions*

Administer Tylenol/Ibuprofen*

May administer a standard does of Tylenol for minor discomfortMay NOT administer a standard does of Tylenol for minor discomfortMay administer a standard does of Ibuprofen for minor discomfortMay NOT administer a standard does of Ibuprofen for minor discomfortMay administer a standard does of Tylenol and/or Ibuprofen for minor discomfortMay NOT administer a standard does of Tylenol and/or Ibuprofen for minor discomfort

Parent / Guardian Name*

First NameLast Name

Parent / Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent Phone Number*

Please enter a valid phone number.

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Relationship to your Child*

Parental signature indicates approval of their daughter attending activities sponsored by IORG in CT.
I give my permission to allow photos of my daughter to be used for promotional or informational purposes.
I assume all risks and hazards associated with my child's participation, including exposure to COVID-19, and release, hold harmless and indemnify the Supreme Assembly IORG, CT IORG and any local assembly from any and all liability from harm, injury or loss. I agree to keep my daughter at home if she is ill.

Signature*

Date*

Date