PARENT'S CONSENT FOR MEDICAL TREATMENT, LIABILITY, AND PUBLICITY RELEASE FORM

Must submit by March 16, 2012.

 


E-mail to: edomingz@texas-ec.org;    Or Fax to: (512) 763-3378

Or mail to: Esther Miranda Dominguez, 2409 Robin Road, Manchaca, TX 78652

 
I/we the undersigned parent(s) or guardian(s) of :
  First Name         Last Name
give my/our consent for him/her to participate in the Government-in-Action Youth Tour from June 14, 2012, through June 22, 2012, sponsored by Texas Electric Cooperatives and co-sponsored with respect to our child by
 
Sponsoring Cooperative Name                                                        

and the National Rural Electric Cooperative Association (NRECA). I/we understand that this participation involves travel within and outside of Texas, and that at times my/our son/daughter may be traveling and/or participating in activities without the direct supervision of a chaperone.

I/we authorize and direct Texas Electric Cooperatives and NRECA, through their staffs and chaperones, to secure any medical or other emergency services the staff and volunteer chaperones in their reasonable discretion may deem necessary or desirable for my/our son/daughter.

I/we hereby release and agree to hold harmless Texas Electric Cooperatives and NRECA, their officers, members, staff and associated organizations together with their heirs, successors, or assigns from any and all causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss or injury related to participation by my/our son/daughter during his/her participation in the Government-in-Action Youth Tour to Washington, D.C.

I/we hereby grant permission to Texas Electric Cooperatives and NRECA to use photographs, likenesses and/or videotape images of my/our son/daughter for publicity purposes related to this activity.
     
Valid E-mail Address:
  
Insurance Policy:
  
Family Physician:
  
Physician's Phone Number:
    
 
EMERGENCY CONTACT
List the names and telephone numbers of two individuals, other than your parents or guardians, who can be contacted in case of an emergency.
     
NAME   RELATIONSHIP   PHONE  
     
NAME   RELATIONSHIP   PHONE  
           
MEDICAL INFORMATION
Do you have any of the following?
    NOTES:  
Asthma:
 
Convulsions / Seizures:
 
Respiratory Problems:
 
Diabetes:
 
Bleeding Problems:
 
High Blood Pressure:
 
Heart Murmur / Heart Disease:
 
Depresssion Disorder:
 
Pregnant:
 
 
Other Medical Information:
 
 
Date of Last Tetanus Shot:
 
           
Medications: List drug names and dosage of medications you take regularly and what ailment it releives and any drugs to which you know that are are sensitive to:
           
Name of Medication:
Purpose:
  
Name of Medication:
Purpose:
  
Name of Medication:
Purpose:
  
Name of Medication:
Purpose:
  
Name of Medication:
Purpose:
  
Name of Medication:
Purpose:
  
Name of Medication:
Purpose:
  
Name of Medication:
Purpose:
  
           
INSURANCE DATA — Note: This information is required for the Accidental Insurance Coverage
         
     
Full Name of Insured Youth   Full Name of Beneficiary  
           
       
Relationship to Insured Youth      
           
         
Address of Beneficiary City State Zip  
           
1. After all information is complete above CLICK the “Submit” Button below, your information is transmitted.
2. You will receive a one-page document (in a PDF file) for signature via email (sent to the email address typed in the Valid Email Address Box).
3. The form MUST be filled out and signed by guardian and faxed to Esther Miranda Dominguez at 512-763-3378.
The document can be scanned and emailed to edomingz@texas-ec.org

 

 


 

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