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 |