2012-cb consent & liability form
DESCRIPTION
ÂTRANSCRIPT
JACK AND JILL OF AMERICA, INC. Reston, Virginia Chapter
15th Cotillion –10th Beautillion
CONSENT AND RELEASE LIABIITY FORM Name of Minor: ______________________________________________________________________ Address: ____________________________________________________________________________ Phone Number: __________________________ Date of Birth: _________________________________ Any known illness: ___________________________________________________________________ Allergies: ___________________________________________________________________________ Taking any medication: ________________________________________________________________ Emergency Contact Information: (1) Name: _____________________________________ Relationship: _________________________
Address: _________________________________________________________________________ Phone Numbers: (h) _______________ (w) ___________________ (c) _______________________
(2) Name: _____________________________________ Relationship: _________________________ Address: _________________________________________________________________________ Phone Numbers: (h) _______________ (w) ___________________ (c) _______________________
I/We give permission for _____________________ (Child’s name) to participate in the 2012 Cotillion/Beautillion activities and I/we, the undersigned parents or guardians do hereby release Jack and Jill of America, Inc., and the Reston Chapter of Jack and Jill from any and all responsibilities and liabilities for any injury or claim resulting from such participation. I/We authorize emergency medical treatment for my child should the need arise for such treatment. I/We grant the release parties the right to photograph and/or videotape my child and further to use said child’s name, face, likeness, voice and appearance in connection with publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein. Health Insurance Information Health Insurance Plan: ________________________________________________________________ Policy Holder’s Name: ________________________________________________________________ Insurance ID #: ___________________________________ Group #: ___________________________ Physician’s Name and Number: __________________________________________________________ I/WE HAVE READ THIS FORM CAREFULLY AND KNOW IT CONTAINS A RELEASE
____________________________ ______________________________ __________________ Name of Parent/Guardian (printed) Signature of Parent/Guardian Date ____________________________ ______________________________ __________________ Name of Parent/Guardian (printed) Signature of Parent/Guardian Date
Please return form to Recruitment Co-Chair: Valeria Edmonds• 20941 Cohasset Terrace, Ashburn, VA 20147• 571-271-9674