ACADEMICS BIG DAY

NAME: ____________________________________________________________________________________

REGION & LOCAL CHAPTER: ___________________________________________________________

EMERGENCY INFORMATION:

CONTACT PERSON 1: ______________________ CONTACT NUMBER: __________________________

CONTACT PERSON 2: ______________________ CONTACT NUMBER: __________________________

MEDICAL INFORMATION:

List all the ailments your child suffers from:

________________________________________________________________________________________________

List any medication your child might need:

________________________________________________________________________________________________

Indicate any allergies with certain medication:

________________________________________________________________________________________________

I take responsibility for my child’s whereabouts after this activity.

I agree to waive, release, indemnify and hold harmless the NFJPIA-Region IV, its officers, members and all the

organizers of this event from any claims of liability arising out of my child’s participation in this activity. I also agree to

waive that NFJPIA-Region IV, its officers, advisers, members and all organizers of this event have responsibility to my

child only within the premises of the venue.

Should my child require medical attention as a result of accident or any serious illness, I do hereby grant and bestow

upon the organizers of this event permission and authority for and on my behalf to authorize any licensed medical

practitioner to render medical aid and treatment.

CONFORME: ___________________________________________ _______________________________

Signature over Name Date