Consent And Release Form printable pdf download

OLIVE CHILDREN FOUNDATION, a 501(c)(3) not-for-profit organization,

strives to prepare our children to be the future leaders of tomorrow.

Consent and Release Form

Date: __________________

Student Information

Name:____________________________ Birth Date:____________ School: ________________Grade :_________

Email: __________________________________

Parent/Guardian’s Information

Name: ___________________________________________ Relationship to Student: __________________

Home Phone #: ______________________________

Alternate Phone #: _______________________

Email: _____________________________________

Address: ___________________________________

The undersigned Parent or Guardian, ____________________________, of _______________________________,

a student in the Olive Children program agrees that:

Medical and Liability Release

___ I agree to release the Olive Children Foundation and its representatives from any claim for personal injury or

damages resulting from my child’s participation in Olive Children’s programs and official program activities.

Emergency Contact

Name: Last _________________________ First ___________________ Best Contact Phone # _________________

In addition to Parent/Guardian

Name: Last _________________________ First ___________________ Best Contact Phone # _________________

Medical Information (Optional)

In the event of emergency or medical need, I give permission for medical treatment. I release the following

information about my child:

A. Physical problems or limitations ________________________________________________________

B. Current medication/s ________________________________________________________________

C. Medication or other allergies __________________________________________________________

D. Insurance Carrier ____________________________ Policy # ________________________________

Physician Name _____________________________ Contact Phone Number ___________________

Photography and Videography Release

___ I authorize and consent to the use of my child’s visual image by the Olive Children Foundation for appropriate

purposes, including but not limited to: still photography, videotape, electronic and print publications, and websites.

I give this consent with no claim for payment.

Field Trip Release

___The above named student has my permission to participate in any or all of Olive Children Foundation’s field

trips unless I retract such permission in writing. I understand that for any field trips, which may require

transportation other than walking, I will be notified in writing or by phone in advance. (See Field Trip List)

43531 Mission Blvd. Fremont, CA 94539

Tel 510-770-8708

Consent And Release Form