WRBC Medical Release & Consent Form
STUDENT INFORMATION
First Name
Last Name
Student Date of birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
Gender
Male
Female
I'd rather not say
Grade
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
School
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Student Phone Number
Permission to text your students regarding events and updates?
Yes
No
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
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