Consent And Release Form


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


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