Indoor Playground Medical Release & Consent Form

CHILD INFORMATION

First Name

Last Name

Student Date of birth

Gender

Child's Age

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Parent First Name

Parent Last Name

Parent Phone Number

Parent Email

Emergency Contact Name

Emergency Contact Phone Number

MEDICAL INFORMATION

Insurance Provider

Insurance Phone Number

Name of Policy Holder

Policy Number

Is your student on any medication?

Yes

No

Please describe any activity restrictions or any chronic illness(es) which would have an effect on the child's participation in any activities.

Please list any allergies or dietary restrictions

CONSENT

Please initial under each statement you are giving permission to WRBC (to include adult volunteer leaders and staff present at the activities):

In the event of an emergency and I (or listed emergency contact) cannot be reached, I allow WRBC to seek appropriate and professional medical attention (where available) to care for my child as needed; to include but not limited to x-rays, injections, anesthesia, medical/dental/surgical care, hospitalization and/or transportation by ambulance.

I acknowledge and accept all risks of injury or death involved in all activities

I accept personal financial responsibility for any bodily or personal injury my child sustains during the activities.

I agree to hold WRBC harmless from any and all liability action, causes of action claims, expenses, and damages.

I agree to the taking of and use of photos and videos of my child taken during activities for use of promotion of WRBC and its activities without any monetary compensation, and without any prior notification of use.

I agree that in the event my child breaks the rules to the point of removal from the activities (as seen necessary by the staff representative), the child will be sent home at my (the parent's) expense to be settled after the activities.

PARENT/GUARDIAN SIGNATURE

Signature