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:

Name: Phone:

Child's physician:

Name: Phone:

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:

Date: