New address: 24 Farnsworth Street, Boston, MA 02210-1409.
Parental Consent and Emergency Medical Release Form
Date(s) of event: Location or destination:
Start time/place: End time/place:
Organization sponsoring the event:
Adult chaperones for the event:
[name(s) and contact information]
I give consent for my child:
to participate in the above mentioned event.
I understand that [name of UU congregation] does not accept responsibility for any property loss or bodily injury incurred during this event.
I give permission for an adult chaperone designated above to secure any needed medical care and treatment required in my absence.
I agree to be responsible for any expenses not covered by my insurance which may be incurred as a result of an accident or medical emergency involving my child.
Parent or guardian name:
Phone # in case of emergency:
Alternate emergency contact:
My child has the following allergies and/or dietary restrictions:
My child has the following medical conditions:
My child takes the following prescription medicines:
Parent or guardian signature:
For more information contact web @ uua.org.
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Last updated on Thursday, October 27, 2011.
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