Form D - Permission Medical Release Form - California (Page 4 of 4) in pdf

CALIFORNIA D ECA D ELEGATE P ERMISSION/MEDICAL R ELEASE F ORM

(Students a nd A lumni a re c ollectively r eferred t o a s “ Delegates” i n t his d ocument)

Conduct C ode E ndorsement, P ermissions t o A ttend C alifornia D ECA S ponsored A ctivities, a nd A uthorization t o

use p ictures o r s tudent n ame i n p ublications.

Release o f C laim f or D amages, E mergency M edical T reatment A uthorization:

Name o f D elegate___________________________________

Date: _ ____________________________

Home A ddress _ ____________________________________

Phone: _ __________________________

_________________________________________________

Date o f B irth: _ _____________________

Name o f H igh S chool _ ______________________________

Phone: _ ___________________________

Advisor ( s) i n C harge_____________________________________________________________________

This i s t o c ertify t hat t he a bove n amed d elegate h as m y p ermission t o a ttend a ll C alifornia D ECA s ponsored a ctivities f or t he

2016-‐2017 S chool Y ear. I a lso d o h ereby, o n t he b ehalf o f t he a bove n amed d elegate a bsolve a nd r elease C alifornia D ECA, t he

school o fficials, t he D ECA c hapter a dvisors, c onference s taff, a nd C alifornia D ECA s taff f rom a ny c laims f or p ersonal

injuries/damages w hich m ight b e s ustained w hile h e/she i s e n r oute t o a nd f rom o r d uring t he D ECA s ponsored a ctivity.

I a uthorize t he a bove n amed a dvisor o r t he C alifornia D ECA s taff t o s ecure t he s ervices o f a d octor o r h ospital f or t he a bove

named d elegate. I w ill i ncur t he e xpenses f or n ecessary s ervices i n t he e vent o f a ccident o r i llness a nd p rovide f or t he p ayment

of t hese c osts.

I g rant p ermission t o C alifornia D ECA a nd i ts s taff/contractors, S tate D epartment o f E ducation, a nd s ponsors/supporters t o u se

the a bove d elegate’s n ame a nd l ikeness ( including p hotographs, v ideo f ootage, s ilhouettes, a nd a udio c lips) i n p ublications,

productions, p romotions a nd o n w ebsites f or i nformational, p romotional a nd o ther r elated p urposes w ithout f urther

consideration, a nd a cknowledge t he r ight o f C alifornia D ECA t o c rop, t reat, e dit, o r o therwise m odify t he p hotographs, v ideo

footage, s ilhouettes, a nd a udio c lips a t t heir d iscretion.

I a lso u nderstand t hat t he c hapter a dvisor d etermines t he c riteria a t t he l ocal s ite, f or i ndividual s tudents a nd a lumni t o a ttend

and p articipate a t a ll D ECA a ctivities.

We h ave r ead a nd a gree t o a bide b y t he s upplied C alifornia D ECA C ode o f C onduct. S hould a c ode o f c onduct v iolation o ccur,

law e nforcement p ersonnel a nd o r s ecurity m ay b e c alled t o a ssist, a nd a c onduct c ode c ommittee m ay b e c alled w ith t he

ultimate p unishment b eing t hat t he s tudent m ay b e d isqualified a nd s ent h ome a t t heir/their f amily’s e xpense a nd/or b e

removed f rom o ffice i f i n a n o fficer s tatus. I f t he d elegate i s s ent h ome r easonable c are s hall b e e xercised t o e nsure a s afe,

expedient, a nd f inancially f easible m ode o f t ransportation b ack t o t he h ome c ommunity o f t he d elegate i nvolved. W e a re

aware o f t he c onsequences t hat w ill r esult f rom v iolation o f a ny o f t he a bove g uidelines.

Student S ignature*__________________________________

Date _ _____________________________

Parent / G uardian S ignature*__________________________

Date _ _____________________________

Chapter A dvisor S ignature*___________________________

Date _ _____________________________

School / ROP O fficial S ignature*________________________

Date _ _____________________________

MEDICAL I NFORMATION

Known a llergies ( drug o r n atural)___________________________________________________________

Special m edication b eing t aken _ __________________________________________________________

Date o f l ast t etanus s hot _ _________________________________________________________________

History o f h eart c ondition, d iabetes, a sthma, e pilepsy o r r heumatic f ever___________________________

Any p hysical r estrictions _ _______________________________________________________________

Other c onditions _ ______________________________________________________________________

Family d octor _ ____________________________

Phone _ _______________________________________

INSURANCE I NFORMATION

Company N ame________________________

Policy N umber _ __________________________________

* T his f orm c onsists o f f our t otal p ages. S ignatures o n t his p age a pply t o t he c ontent i ncluded o n a ll f our p ages.

CA D ECA L ACE C onference 2 016

Form D -‐ P age 4 o f 4

Form D - Permission Medical Release Form - California Page 4

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