Name of Student________________________________________________
Address__________________________________________________
Contact Phone #__________________________
Date of Birth_____________Age_____________ Grade_____________
What, if any, physical disabilities or allergies does your child have?_______________________________________
Remarks______________________________________
Participation Approval By Parents
Being the parent or legal guardian of this child, I give my consent for him/her to take part in said program sponsored by the Belle Plaine Parks & Recreation Department, and will take full responsibility for any injury that may occur during this program. I affirm that the above information is true and complete to the best of my knowledge. I further state that this child has no physical or emotional impairments that will interfere with normal participation except as noted above.
_________________________________________________________
Signature of Parent or Guardian
Emergency Care Consent
I hereby give my consent to authorize personnel of said recreation program to obtain professional medical care for the above named child in case of injury or illness arising during his/her participation in said program.
In case of emergency and where the undersigned cannot be reached, the person to contact in the event of injury or illness is:
Name_____________________________Phone___________________
________________________________Signature of Parent or Guardian