Girls Rise Up Participation Release Form

PARENT/GUARDIAN AUTHORIZATION

As a parent/guardian, I understand that my daughter will be under the supervision of the adult volunteers of Girls Rise Up. I give my full permission for her to attend gatherings offered by Girls Rise Up. Every Girls Rise Up event is carefully planned and adequately supervised by mature adults. However, even with careful planning and precautions, unforeseen events can occur. By signing this form, I agree to assume and accept all risks and hazards inherent in Girls Rise Up gatherings and/or events and hold harmless Girls Rise Up for any injury that may occur. In the event my child becomes ill or is injured while participating, I am providing my insurance Information below.

Child's Name:

First Name

Last Name

Age:

Date of Birth:

YYYY

Parent/Guardian:

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email:

Phone:

(###)

###

####

Alternate person to contact:

First Name

Last Name

Phone:

(###)

###

####

Are there any disabilities that would limit the child’s activities?

Yes

If yes, please describe:

Is the child currently taking any prescription medication?

Yes

If yes, please describe:

Name of insured:

First Name

Last Name

Relation to child:

Employer's Name:

Employer's Phone:

(###)

###

####

Insurance Company Name:

Insurance Company Phone:

(###)

###

####

Group Name:

Group Number:

Subscriber ID:

Photo Waiver:

Girls Rise Up has my permission to use my or my child’s photograph publicly. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Yes

Electronic Signature:

First Name

Last Name

Today's Date:

YYYY

Girls Rise Up Participation Release Form

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