Extra Curricular Parental Consent Form 2021-22

Student Information

Student Name*

First NameLast Name

DBIS Student ID*

Birth Date*

DayMonthYear

Year Group*

Gender*

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Country

Parent/Guardian Information

Name*

PrefixFirst NameLast Name

Home Phone*

Mobile number*

E-mail*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone number*

Alt. Phone Number*

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by DBIS during the selected activities.

I have read and agree to the medical release and authorisation statement below.

Medical Release and Authorisation

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to DBIS and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the student's admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor student, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

DBIS Extra Curricular Activities Parental Consent Form 2021-22