Child Overnight And Medical Release Form printable pdf download

Child Overnight And Medical Release Form

CHILD OVERNIGHT AND MEDICAL RELEASE

FORM

Jewish Community Center of San Luis Obispo

JCCSO Sleepover date:__________________________________

One of these Overnight and Medical Release forms must be filled out for each child

attending the sleepover.

Child’s Name_________________________________________________________

Birth date__________________________ Sex_______ Age____________________

Parent/Guardian of child_________________________________________________

Day phone__________________________ Night phone________________________

Mailing Address:_______________________________________________________

City:______________________________ State:_________ Zip Code:____________

IN CASE OF AN EMERGENCY please list two people other than parent/guardian who

can be reached during overnight hours.

Name_______________________________________ Phone #____________________

Please list any special conditions (allergies, special medications, etc.) for the child.

_______________________________________________________________________

I understand that the JCCSLO staff may, in its sole discretion, call 911 to arrange any medical treatment,

and that the JCCSLO disallows all responsibility for the cost of this or any other treatment.

I, the parent and/or legal guardian of the above-mentioned child, on behalf of the child, his/her parents or

legal guardians, heirs, and legal representatives, do hereby release, acquit or forever discharge and agree to

hold harmless, the JCCSLO and their respective employees and agents from any and all claims, demands,

rights, damages, losses, injuries or causes of action whether known or unknown, or foreseen or unforeseen,

arising out of any personal injury (or otherwise) sustained by or resulting from the child’s participation in

the JCCSLO Sleepover.

I understand that the parties released admit no liability of any sort.

Signature_________________________________________ Date___________________

Child Overnight And Medical Release Form