Parental Permission Form

 

Student Name: __________________________________________       Age _____       Grade ______

 

Address: ___________________________________________________________________________

 

Phone: _____________________________        Email:  ____________________________________

 

Father (or guardian): ___________________________ Phone (h)______________ (w) ______________

 

Address (if different from above): ________________________________________________________

 

Mother (or guardian): __________________________ Phone (h)______________ (w) _______________

 

Address (if different from above): ________________________________________________________

 

Physician’s Name: ______________________________________Phone: _____________________

 

Hospital: _________________________________

 

In case of emergency please notify: _____________________________________________________

 

Relationship to child: ________________________ Phone (h): ______________ (w) ______________

 

Please list any allergies or food limitations: _________________________________________________

 

Please list any medical conditions or limitations we should be aware of: ____________________________

 

_____________________________________________________________________________________

 

Other special considerations or concerns: __________________________________________________

 

____________________________________________________________________________________

 

I give permission for the Arts Council of Pendleton staff, instructors, or volunteers to seek emergency medical assistance in the event that they are unable to reach me (circle one): YES    NO

 

I give permission for my child to leave the building on walking field trips (circle one): YES    NO

 

The following persons ONLY have permission to pick up my child:

 

____________________________________________________________________________________

 

My child has permission to walk home (circle one): YES    NO

 

The Arts Council of Pendleton has permission to use my child’s name and picture for any broadcast,

tele-broadcast, Internet or print media purpose (circle one): YES    NO

 

Informed Participant Consent

I, the parent or guardian of the above name participant, understand the possibility of injuries resulting from the activities indicated above or other activities sponsored by the Arts Council of Pendleton. I hereby acknowledge and accept all risks and hazards incidental to participation in such activities. I hereby release, absolve, indemnify, and hold harmless the Arts Council of Pendleton, its employees and agents from any liability for injury whether to person or property of the participant.  In case of personal injury to participant, I hereby waive any and all claims against the Arts Council of Pendleton, its employees and agents.

 

Parent or guardian (please print):  _______________________________________________________

 

Signed: ____________________________________________________      Date: _________________

☼ Registration Form  ☼

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