I grant permission for the administration of first aid care to the person named below by people in charge of the activity as their judgment deems advisable and to make the necessary referrals to qualified physicians for treatment of illness or accidents or a more serious nature.  I understand that I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life.  In case of medical emergency, I understand that every effort will be made to contact the parent(s)/guardian(s) of the participant.  In the event that I cannot be reached, I hereby give permission to the physician selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my son/daughter.  I also give permission for necessary transportation.

Parent/Guardian (if this form is not being submitted electronically, your name should first be printed followed by your signature.)

Date (d/m/yyyy) - Telphone Number (include area code) and an alternate phone number if available.

Other Emergency Contact (in case parent/guardian is not available).  Include name and telephone number (including area code)

Policy in the name of:

Insurance Company:

Policy Number:

Identification Number and/or Social Security Number: