EMERGENCY INFORMATION & APPLICATION FORM

DEAR PARENTS:  PLEASE FILL OUT ALL THE INFORMATION BELOW FOR EACH CHILD SO THAT IN THE EVENT OF AN             ILLNESS, EMERGENCY OR OTHER SITUATION WHERE YOU ARE  NOT AVAILABLE, WE WILL KNOW WHOM TO CONTACT AS SOON AS POSSIBLE.  THANK YOU FOR YOUR COOPERATION.

  PLEASE PRINT

NAME OF CHILD_________________________AGE________________

ADDRESS____________________________________________________

DATE OF BIRTH_____________________________________________

HOME PHONE______________________CELL PHONE_____________

WORK PHONE_______________________

MOTHER_____________________________________________________

FATHER______________________________________________________

LIST OF ADULTS (18& UP) ALLOWED TO PICK UP YOUR CHILD

1.___________________________________________________________

2.___________________________________________________________

EMERGENCY CONTACT PEOPLE (LIST ADULTS ONLY PLEASE)

1._____________________________________________________________

2._____________________________________________________________

CLOTHING SIZE_______________________SHOE SIZE_____________

MEDICAL INFORMATION

"This section must be complete in order for this application to be valid."

MEDICAL INSURANCE_______________POLICY NUMBER________

List any injuries________________________________________________ 

List any medications____________________________________________

List any allergies_______________________________________________

Child's Physician______________________Phone_________________________

Preferred Hospital_____________________________________________

Should an emergency arise, you may have my permission to have my child taken to the nearest hospital by ambulance if necessary, (if out of town) and to be treated by the facility's staff.  You may have my permisssion to contact my child's physician to obtain and convey information regarding my child's health.

SIGNATURE OF PARENT____________________________________________________

PARENT RELEASE FORM

By signing this form your are releasing the following directors from liability and waiving your rights to assert a claim against the team for injury to your child.

I hereby release, Shirley Banks, Rosalie Ouinones  (SOUL-O-ETTES DRILL TEAM), from liabilty for myself and my child (and any guests) for all damage and expense.

I give my permission for my child to take part in any competition trip or fundraisers sponsored by the above named directors and the team.

Signature of parent/guardian___________________________Date_________