NOTE:
Emergency Medical Technicians & Ambulance will be dispatched for ALL medical concerns. As well as the administration of medications.
Effective Dates: From
[from date] To [to date]
MINOR
First Name:
Middle Name:
Last Name:
Date of Birth:
Sex:
Youth Age:
Grade:
Street Address:
City:
State:
Zip:
Allergies / Special Health Concerns / Medications / Dietary
Needs:
Date of Last Tetanus Shot:
Surgery or Serious Illness History:
Physicians Name:
Physicians Phone:
Health Insurance Company Contact Info:
Insured's Name:
Policy Number:
ID Number:
ADULT/PARENT/LEGAL GUARDIAN
Adult Name:
Home Phone:
Cell phone:
Parent(s)/Legal Guardian/Adult Participant age 21 or over
My child may participate in the above stated event. No
Transporation Services will be provided to and from the event. I give
permission for my child / myself to receive emergency medical care if
necessary. I give the adult chaperones / leaders the authority to act on my
behalf with respect to my child's/my own health and safety while at the event,
with the understanding that I/emergency contact listed above will be contacted
as soon as possible should the need arise. I accept full responsibility for any expenses
for medical treatment for my child/ myself. I released A Geeks World Tour 2020,
South San Francisco Library, and Affiliates, and its representatives from
liability in the event of accidental injury or illness.
I declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct.
Today's Date:
Signed: [signature]
Print:
INCOMPLETE FORMS WILL NOT BE PROCESSED.
eladiomalolot © 2016. all rights reserved.
