Permission and Emergency Form
Provide emergency and permission details for students. All fields are optional.
Student Name
*
First Name
Last Name
Parent or Guardian Name
*
First Name
Last Name
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Hub
Please Select
Hub 1
Hub 2
Hub 3
Other
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Notes
Transportation Notes
Emergency Medical Treatment Authorization & Liability Release In the event of illness or injury during Village Indiana hub activities, and if I cannot be reached, I authorize The Village Indiana staff, volunteers, and mentors to secure any medical treatment deemed necessary for my child, including transportation to a hospital or medical facility and treatment by a licensed physician or medical personnel. I understand The Village Indiana will make reasonable efforts to reach me or the emergency contact listed above before treatment is administered, except where immediate treatment is necessary to protect the health or safety of my child. I further release and hold harmless The Village Indiana, its staff, volunteers, and mentors from any and all liability, claims, or causes of action arising from injury, illness, or loss related to my child's participation in Village Indiana hub activities, except in cases of gross negligence or willful misconduct. By checking the box below and signing, I certify that the information provided on this form is accurate and that I am the parent or legal guardian of the student named above, with legal authority to give this permission.
I have read, understand, and agree to the Emergency Medical Treatment Authorization and Liability Release above, and I give my permission.
*
I acknowledge and give permission
Parent/Guardian Signature (type full legal name)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: