Summer @ The CenterEmergency Info Permission and Waiver 1st Student Name * First Name Last Name Does this child have allergies or medical conditions? * Yes No Please relay anything else important for me to know about your Health health and well-being. 2nd Student Name, if applicable First Name Last Name Does this child have allergies or medical conditions? * Yes No Please relay anything else important for me to know about your Health health and well-being. Primary Adult Emergency Contact Information * Please fill in the following information for the adults that are responsible day-to-day, and are primary contacts for the child. In the event of an emergency, I will contact the following person(s) in the order presented: First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Does the student primarily live at this address? Yes No Relationship to student * Second Adult Emergency Contact Information * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Please list the full name and phone number of any individuals (ove the age of 18) authorized to pick up your child. MEDICAL CONSENT WAIVER AND RELEASE OF LIABILITY * * I authorize my child to walk to the rail trail with Center staff for outdoor exploration of themes. * I authorize The Center staff to administer emergency first aid when appropriate. * I understand that every effort will be made to contact me in the event of an emergency where my child requires medical attention. * I authorize a Center staff member to transport my child or to secure transport to Anna Jaques Hospital and to secure necessary medical treatment from the physician on duty. * In the event of serious illness or injury not requiring emergency treatment, I understand that I will be called and asked to take my child home or to a physician. I authorize the person(s) listed to be contacted in the event of an emergency. * I understand ONLY the person(s) listed will be allowed to release my child with prior notification. * I agree to release, hold harmless, and discharge The Center, and all of its employees, volunteers, contractors, and representatives from any and all claims or causes of action. I waive any right to legal action for personal injury or any associated costs that may arise from this child(ren)'s participation in any activities or use of the facilities. * I agree to pay all medical expenses not covered by my insurance. I agree I authorize The Center to release the information on this form to the hospital. * I agree I have carefully read this WAIVER AND RELEASE, understand, consent, and grant authority as noted above. * I agree I HEREBY CERTIFY that I am the parent or guardian of : * If two children are listed, please write both names. Parent Name * First Name Last Name Today's Date * MM DD YYYY Thank you!
