Medical and Media Release Form

Medical and Media Release Form

Permiso de tratamiento medico y fotografia de niño
Electronic Signatures. The parties acknowledge and agree that this permission and medical release form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via pdf) of an original signature./Firmas electrónicas. Las partes reconocen y acuerdan que este permiso y formulario de autorización médica pueden formalizarse mediante firma electrónica, la cual se considerará firma original a todos los efectos y tendrá la misma validez y efecto que una firma original. Sin limitación, se entenderá por «firma electrónica» las versiones enviadas por fax de una firma original o las versiones escaneadas y transmitidas electrónicamente (por ejemplo, en formato PDF).

I agreeI do not agree
Child Information

Información de niño(s)
Name*

First NameLast Name
Age*
If signing up more than 1 child:

Si tiene mas que un niño/a
Name/Nombre

First Name/Primer nombreLast Name/Apellido
Age/Edad
Name/Nombre

First Name/Primer nombreLast Name/Apellido
Age/Edad
Name/Nombre

First Name/Primer nombreLast Name/Apellido
Age/Edad
Parent/Emergency Contact Information
Name/Nombre*

First Name/Primer nombreLast Name/Apellido
Primary Phone Number/Número de teléfono (primario)*

Area CodePhone Number
Secondary Phone Number/Número de teléfono (secundario)

Area CodePhone Number
Email/Correo electrónico
example@example.com
Medical Information

Información medica de niño
Does the participant require a special diet?/¿Su hijo necesita una dieta especial?*

Yes/SíNo
Please explain the dietary restrictions/Por favor indique restricciones de dietéticas
Does the participant have any allergies?/¿Su hijo/a tiene alergias?*

Yes/SíNo
Please list the allergies/Por favor indique las alergias
Is the participant taking any medication or over-the-counter (OTC) drugs?/¿Su hijo/a está tomando algún medicamento?*

Yes/SíNo
Can the participant self-administer his or her medication?/¿Su hijo/a puede administrarse sus propios medicamentos?

Yes/SíNo
List all prescription or over-the-counter medications the participant is taking/Por favor indique los medicamentos del niño/a:
Physical Conditions that limit activity

Condiciones físicas que limitan actividades
Does the participant have a chronic or recurring illness?/Participante tiene alguna enfermedad crónica o recurrente*

Yes/SíNo
Please Explain/Por favor explique
Has the participant had surgery or a serious illness in the past year?/Participante a tenido cirugía o una enfermedad grave en el último año*

Yes/SíNo
Please Explain/Por favor explique
Identify any other needs or considerations the participant has that the event or activity planner should be aware of/Otras necesidades o consideraciones del participante que se debe(n) saber por el evento/dirigientes de él:
Signature

I give permission for my child/youth to participate in the event and activities listed above (unless noted) and authorize the adult leaders supervising this event to administer emergency treatment to the above-named participant for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover this event and travel to and from this event. The participant is responsible for his or her own conduct and is aware of and agrees to abide by Church standards, camp, or event safety rules and other pertinent instructions. Participants’ conduct and interactions should abide by Church standards and exemplify Christlike behavior. Parents and participants should understand that participation in an activity is not a right but a privilege that can be revoked if they behave inappropriately or if they pose a risk to themselves or others.
Participant's Signature*

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Parent or guardian signature*

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Parent or Guardian photo consent*

I consent for my child to be photographed during this activity and for the photos to be distributed through social media/marketing of WASB./Doy mi consentimiento para que mi hijo/a sea fotografiado durante esta actividad y para que las fotos se distribuyan a través de las redes sociales/marketing de WASB.I do not consent for my child to be photographed during this event./No doy mu consentimiento para que mi hijo sea fotografiado durante este evento.
Your child will be given the opportunity to opt-out of group photos. Please make sure they are aware that they should not participate in photo opportunities.
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Medical and Media Release Form

Child Information

If signing up more than 1 child:

Parent/Emergency Contact Information

Medical Information

Physical Conditions that limit activity

Signature