Parental Consent and Liability Release Form

Parental Consent and Liability Release Form
PARTICIPANT NAME
AGE
DOB
PARENT(S)/GUARDIAN NAME(S)
Grade
PARENT/GUARDIAN CELL #S
TO WHOM IT MAY CONCERN:
The undersigned do(es) hereby give permission for our (my) child(ren):
(“Participant” Name),
To attend and participate in all activities sponsored by the MCC ACADEMY from this day, August, 2014, forward.
LIABILITY RELEASE: In consideration of MCC ACADEMY allowing the above participant to partake in
MCC ACADEMY activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless
MCC ACADEMY, its staff, founders, volunteers, counselors, chaperones, cooperating businesses or service providers
under contract with MCC ACADEMY from any and all liability, claims or demands for accidental personal injury,
sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the
undersigned and the participant while involved in the activities. We (I) the parents or legal guardian(s) of this
participant hereby grant our (my) permission for the participant to participate fully in all MCC ACADEMY activities.
Furthermore, we (I) [and on behalf of our (my) minor participant(s)] hereby assume all risk of accidental
personal injury, sickness; death, damage and expense as a result of participation in recreation and work activities
involved therein.
Further, authorization and permission is hereby given to said MCC ACADEMY to furnish any necessary
transportation, food and lodging for this participant as required for the MCC ACADEMY activities. The undersigned
further hereby agree to hold harmless and indemnify said MCC ACADEMY for any liability sustained by said
MCC ACADEMY as the result of the negligent, willful or intentional acts of said participant, including expenses
incurred attendant thereto.
MEDICAL TREATMENT PERMISSION IN THE CASE OF AN EMERGENCY: We (I) authorize an
adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical,
surgical, or dental diagnosis or treatment or hospital care, to be rendered to the minor under the general or special
supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on
the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay
all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned child
or youth pursuant to this authorization.
TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for our (my)
child(ren) to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in
activities sponsored by MCC ACADEMY. My child/youth and I understand that SEAT BELT SHALL BE WORN
AT ALL TIMES during transportation.
PHOTOGRAPHY: I hereby consent to my child being interviewed or videotaped at events sponsored by
MCC ACADEMY. Furthermore, I consent to the publication, exhibition or reproduction of any such interview
material, photograph or videotapes to be used for public relations, news articles or telecasts, education, advertising,
research, inclusion on the MCC ACADEMY website, face book, fundraising or any other purpose. I, the
undersigned, also consent that I will not seek compensation for my child’s participation here.
Medical Insurance: Yes No
Insurance Company:
Policy/Group ID #:
Emergency Name & Tel #:
Allergies/Medical Conditions;
Parent/Guardian Signature:
Date: