Permission Slip and Medical Form

Permission Slip and Medical Form

Provide your details to authorize release.
Student Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Grade
Boy or Girl
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Name (Other than Parent/Guardian)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does the student have any allergies?
If yes, please list the allergies
Current Medications
Known Medical Conditions
Family Physician
Date

MonthDayYear
Date
By checking this box, I understand that personal injury can and may occur to my child, and I hereby authorize CT New Caney Youth, or another appointed youth advisor, to seek and consent to emergency medical attention for my child as needed; and I further agree to be liable for and to pay all costs incurred in connection with such medical attention. I hereby release CT New Caney Youth its employees, agents and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in or traveling to and from this event.
Should be Empty: