Media Release, Event Agreement and Release, Parent/Guardian Consent and Release, Medical Information

Medical Release, Event Agreement and Release, Parent/Guardian Consent and Release, Medical Information

To be completed by all Participants and by Parent/Guardian if under 21. Return to Registration purchase after submitting Release form to complete Registration. Submission of Release form does not complete Registration.
Participant Information
Name
Chapter/Organization
Participant Type
Consent and Signatures
Media Release (Required for all participants)

I hereby assign and grant to DeMolay International the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me by DeMolay International, and I hereby release DeMolay International from any and all liability from such use and publication.

I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of DeMolay International and I specifically waive any right to any compensation I may have for any of the foregoing.
Media Release Agreement
Event Consent and Release (Required for all participants under 21 years of age)
I hereby promise to conduct myself in a responsible manner and abide by DeMolay rules and regulations and the rules and regulations of this DeMolay event. I will be subject to being dismissed from the event and sent home at my own expense if I do not abide by this promise. I shall indemnify and hold DeMolay International, The International Supreme Council of the Order of DeMolay, and all Affiliated Organizations harmless from and against all penalties, losses, costs, damages, suits, judgments, claims, demands, expenses and liabilities of any kind or nature whatsoever, arising directly or indirectly out of or in connections with my attendance at the DeMolay event.
Event Consent and Release Agreement
Participant Signature
Participant Signature Date

MonthDayYear
Date
Parent/Guardian CONSENT and RELEASE (Required for all participants under age 21)
I, the undersigned Parent/Legal Guardian of the above identified participant, do hereby give my consent and permission for them to participate in all activities and events conducted by Oregon State Council, DeMolay International.

I agree to the foregoing Event Consent and Release and to the foregoing Media Release.

I agree to release and hold harmless members, advisors, and officers of DeMolay International, from all claims or cause of actions, which the undersigned has or may have. In the event of injury or illness to the above named participant, I hereby authorize any Advisor in attendance to secure, and any healthcare provider in attendance to provide such emergency treatment as may be deemed necessary by those present including but not limited to hospitalization, medication administration, diagnostic radiology and procedures, surgery, and blood transfusions. I understand reasonable efforts will be made to contact me prior to medical treatments.
Parent/Legal Guardian Consent and Release Agreement
Parent/Legal Guardian Signature. Required if participant under 21.
Parent/Legal Guardian Signature Date. Required if participant under 21.

MonthDayYear
Date
Parent/Legal Guardian Contact
Parent/Legal Guardian Name

First NameLast Name
Parent/Legal Guardian Email
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact, Insurance and Medical History, required for participants under 21, requested for others.
Emergency Contact Name
Emergency Contact Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Carrier
Policy Holder
Policy/Group #
Telephone Number for Emergency Insurance Authorization
Please enter a valid phone number.Format: (000) 000-0000.
Medical History and Special Accommodations
Currently under care for any illness or injury?
If yes, explain current illness or injury care
Had any surgeries or significant injuries in the past 12 months?
If yes, explain surgeries or significant injuries in the past 12 months
Any food, drug, or contact allergies?
If yes, list any allergies and describe the reaction
Will the participant have any prescribed or over-the-counter medications with them?
If yes, list any medications and when each medication is to be taken
Disability or physical limitations that may affect participation or require special arrangements
Special dietary needs or restrictions
Other condition or concerns we should be aware of
Submit Release and Consent form and return to the Registration page to complete registration. Registration link.
Should be Empty:

Medical Release, Event Agreement and Release, Parent/Guardian Consent and Release, Medical Information

Participant Information

Consent and Signatures

Parent/Legal Guardian Contact

Medical History and Special Accommodations