Skip Navigation

Events Permission Release

Kids’ Night Out Emergency Contact and
Medical Care Consent Form

"*" indicates required fields

Child's Information

Child's Name*








MM slash DD slash YYYY

Legal Guardian Information

Name*







Address*


















Is this the primary address of the child?

Legal Guardian Information

Name







Address















Is this the primary address of the child?

Emergency Contact(s) Information

Name*




Name*




Name




Person(s) to whom child may be released

Name*




Name




Name




By signing here, I authorize WITF Staff to dismiss my child as a “walker” at the designated time.
Time of Dismissal (not later than 7:35pm)

:


Child's Physician or Medical Care Provider Information

Physician/Medical Provider Name*




Address*















Name of health insurance provider




Parental Consent

A signature is required below for each item for which you give parental consent
Administration of minor first-aid treatment
Emergency medical treatment
Emergency medical transportation
Transportation by facility personnel
Administration of prescription medication (must be accompanied by medication form)
Administration of non-prescription medication (must be accompanied by medication form)
Authorization for my child to participate in physical activities
Authorization for my child to photographed and/or videotaped for the purpose of promoting WITF, Inc.'s programs and partnerships

Date

This field is for validation purposes and should be left unchanged.