Emergency Contact Form

indicates a required answer

Insurance and Emergency Contact Form

This form must be completed by all members and guests to participate in any activity

I, the undersigned parent/guardian, do hereby grant permission for my child(ren) listed above to participate in CHET-NW Activities. In order that my child may receive the proper medical treatment in the event that he/she may sustain injury or illness during any CHET-NW activity, I hereby authorize a supervising adult to obtain or provide medical treatment for my son/daughter for such injury or illness during the CHET-NW activity, and I hereby hold CHET-NW, as well as its representatives, harmless in the exercise of this authority. I hereby release from any liability CHET-NW and all adult supervisors and class helpers in the event of any accident en route or during activities. I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my son/daughter for physical illness or injury that he/she may sustain during any CHET-NW activity.

I also understand the P.E. Program includes activities such as running, jumping, stretching, and other physical exertion to benefit the students. Understanding that there is always a possibility that my son/daughter may sustain physical illness or injury, I acknowledge and understand that my son/daughter is assuming the risk of injury or illness by his/her participation, and I further release CHET-NW and its representatives from any claims for personal illness or injury that my son or daughter may sustain during P.E. activities.

I am aware that if my child has a medical condition that prevents or prohibits him/her from participation in any P.E. activity (i.e. running, jumping, stretching) I must notify the P.E. Coach on the day of participation.

I accept these terms.

1. *	Please type your full name in the box below to indicate your acceptance of these terms:

2.	Spouse's signature. Please type your full name in the box below to indicate your acceptance of these terms:

Insurance Information

3.	Policy holder's Name:

4.	Insurance Company Name:

5.	Policy Number:

Emergency Contact

6. *	List an emergency contact other than a parent or guardian:

7. *	Emergency contact home phone:

8.	Emergency contact cell phone:

9. *	Emergency contact's relationship to the student: