2010 KANSAS ENVIROTHON
Attendees Release Form
This form must be filled out and signed by all attendees (teachers, students, parents, agency employees, volunteers) of the 2010 Kansas Envirothon. If attendee is a minor, the form must be signed by the parent or legal guardian.

Attendees Name ______________________________________________________

Home Address _______________________________________________________
                      _______________________________________________________

Home Phone  _______________________   Work Phone _____________________
                                                            
(if team member, provide parent's work number)
County _____________________     School/Group  _________________________

Emergency Contact ______________________________  Phone ______________

Relationship to Attendee  _______________________________________________

Insurance Provider __________________________  Policy # _________________

Known Allergies or Medical Conditions ___________________________________ ___________________________________________________________________

Medication currently being taken -  please name and give administering instructions.
___________________________________________________________________

Date of last Tetanus Booster: ________________________  (month and year)

*I understand this is an outdoor event, the event may be strenuous and adverse weather conditions may occur. I acknowledge that there is the possibility of accident or injury while attending the Kansas Envirothon competition. Nevertheless, I assume the risk involved. I hereby release the Kansas Association of Conservation Districts, District emloyees, and all others participating in the Kansas Envirothon competition. This release is total and without reservation on my part. By signing this form, I acknowledge that I have read this form and understand it.

* I hereby give my consent to the use of any photographs taken of me by officials of the Kansas Envirothon, or their representatives, to be used for editorial, promotional or Kansas Envirothon website use only.

________________________________________     Date ____________________
(*signature of attendee gives consent for full participation, medical release, travel and photo consent.)

I, _______________________ give permission for my child, __________________
      (parent/guardian)                                                         (minor's name)

to travel to the Kansas Envirothon in the care of _____________________________,
                                                                        (teacher/advisor's name)
for the purpose of attending the 2010 Kansas Envirothon competition.

________________________________________   Date ______________________
(* Signature of Parent/Guardian gives consent for full participation, medical relase, travel and photo consent.)

Page Last Modified 06/15/2009