10TH PICPA NATIONAL ACCOUNTING QUIZ SHOWDOWN

WAIVER

NAME (Last Name, First Name, Middle Initial):

____________________________________________________________________________________

REGIONAL COUNCIL: LOCAL CHAPTER:

EMERGENCY INFORMATION:

CONTACT PERSON 1: ________________________________

CONTACT NUMBER: ___________________

CONTACT PERSON 2: ________________________________

CONTACT NUMBER: ___________________

MEDICAL INFORMATION (Write None if nothing needs to be specified):

List all the ailments of your child:

_____________________________________________________________________________________
List any medication your child may need:
______________________________________________________________________________________
Indicate any allergies with certain medications:
______________________________________________________________________________________

I agree to waive, release, indemnify, and hold harmless the NFJPIA, its officers,
members, and all the organizers of this event from any claims of liability arising
out of my childs participation in this activity. I also agree that NFJPIA, its officers,
advisers, members, and all organizers of this event have responsibility to my
child, only within the premises of the venue.
I will take sole responsibility for my childs whereabouts after this activity. 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:

_________________________________________
Father/Mother/Guardian
*SIGNATURE OVER PRINTED NAME*