EVENT WAIVER

JULY 14, 2013

Event: 6th NAQDOWN

NAME:____________________________________________________________________________________
REGION & LOCAL CHAPTER: ___________________________________________________________
EMERGENCY INFORMATION:
CONTACT PERSON 1: ______________________ CONTACT NUMBER: _______________________
CONTACT PERSON 2: ______________________ CONTACT NUMBER: _______________________

MEDICAL INFORMATION:
List all the ailments your child suffers from:
_____________________________________________________________________________________________
List any medication your child might need:
_____________________________________________________________________________________________
Indicate any allergies with certain medication:
_____________________________________________________________________________________________
I take responsibility for my childs whereabouts after this activity.
I agree to waive, release, indemnify and hold harmless the NFJPIA, its officers, members
and all the organizers of this event from any all claims of liability arising out of my childs
participation in this activity. I also agree to waive that NFJPIA, its officers, advisers,
members and all organizers of this event has responsibility to my child only within the
premises of the venue.
Should my child require medical attention as a result of accident or any serious illness, I do
hereby grant and bestow upon the organizers of this event permission and authority for
and on my behalf to authorize any licensed medical practitioner to render medical aid and
treatment.
CONFORME: _________________________________________
Signature over Name

_________________________
Date