SUMMER ADVENTURES SUMMER SCHOOL

STUDENT NAME_______________________________________________________________

(Parent initial each blank)

_____I GIVE PERMISION FOR MY CHILD TO PARTICIPATE IN ADVENTURES SWIMMING, COMMUNITY ACTIVITIES AND LUNCH PROGRAM.

_____I GIVE PERMISION FOR MY CHILD TO BE PHOTOGRAPHED AS A STUDENT IN THE ADVENTURE PROGRAM AND AGREE THAT THESE PHOTOGRAPHS MAY BE USED IN THE FUTURE WITHOUT FURTHER NOTICE.

_____I RELEASE ARC/SOUTHEAST MS, IT’S EMPLOYEE, HATTIESBURG AND LAMAR COUNTY SCHOOLS FROM LEGAL RESPONSIBILITY FOR INJURY SUSTAINED BY MY CHILD WHILE TRAVELING TO/FROM OR ATTENDING ANY OF THE ADVENTURES ACTIVITIES.

AUTHORIZATION FOR TREATMENT

IN THE EVENT OF AN EMERGENCY, I WISH FOR THE FOLLOWING HOSPITAL TO TREAT MY CHILD (You may choose one or both).

______________FORREST GENERAL HOSPITAL

______________WESLEY MEDICAL CENTER

DOCTOR/PEDIATRICIAN_____________________________________________________

PHONE___________________

PARENT SIGNATURE__________________________________________________________

WITNESS_______________________________________________________________________

DATE______________________________

Frances Bounds

2013-03-08

Arc