DSM Medical Release

Name *

First Name

Last Name

Sex: *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

T-Shirt Size *

XS

S

M

L

XL

XXL

Please add me to the Grow Hubs & the email list: *

Yes

No

Name

First Name

Last Name

Mother

Father

Guardian

Address

(If different from student)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please add me to Grow Hubs & the email list: *

Yes

No

Date of Last Tetnus Shot

MM

DD

YYYY

Physician's Phone *

(###)

###

####

Medical Release *

I give permission for my child to participate in DSM of Dutilh Church, Cranberry Twp., PA including travel to events being attended by DSM. I understand that travel will be provided by a personal or rental vehicle driven by an adult chaperone/leader who is age 24 or older with a valid driver's license. I give permission for my child to receive emergency medical care if necessary. I give the adult chaperones/leaders the authority to act on my behalf with respect to my child's health and safety while at the event, with the understanding that I (emergency contact listed above) will be contacted as soon as possible should the need arise. I accept full responsibility from liability in the event of accidental injury or illness.

I agree