Common use of Additionally Clause in Contracts

Additionally. I appoint RCB as my lawful attorney-in-fact, to act for me in my name and xxxxx and on my behalf, in any way that I would, in the reasonable and sole judgment of RCB be expected to act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity: • To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. • The release/indemnification/defense provisions above shall apply to any such decision or action. • I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. • The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. • This power of attorney shall lapse automatically upon completion of the activity listed above that my child is participating in or attending and related activities, and travel if any, and the return of my child to me or my designee. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. • I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: • List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: • If any change occurs in the information which I have provided with respect to emergency contacts or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Diocese of Worcester, and I hereby release, indemnify and agree to defend under the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. By signing below I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCB’s agreement to allow my child to participate in this voluntary activity, trip or event, and as an inducement to the RCB to permit such participation, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form Name of my child Date of Birth of my child Complete Address City, State, Zip Code #1 Emergency Contact (other than yourself): Relationship Phone - Work: Home: Cell: Family Doctor’s Name Phone: Child’s Health Insurance Provider Membership Number

Additionally. I appoint RCB as my lawful attorney-in-fact, to act for me in my name and xxxxx and on my behalf, in any way that I would, in the reasonable and sole judgment of RCB be expected to act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity: • To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. • The release/indemnification/defense provisions above shall apply to any such decision or action. • I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. • The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. • This power of attorney shall lapse automatically upon completion of the activity listed above that my child is participating in or attending and related activities, and travel if any, and the return of my child to me my designee or my designeeme. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. • I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: • List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: • If any change occurs in the information information, which I have provided with respect to emergency contacts contacts, or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Diocese of Worcester, and I hereby release, indemnify and agree to defend under the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. By signing below I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCB’s agreement to allow my child to participate in this voluntary activity, trip or event, and as an inducement to the RCB to permit such participation, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form Name of my child Date of Birth of my child Complete Address City, State, Zip Code #1 Emergency Contact (other than yourself): Relationship Phone - Work: Home: Cell: Family Doctor’s Name Phone: Child’s Health Insurance Provider Membership Number

Additionally.  I appoint RCB as my lawful attorney-in-fact, to act for me in my name and xxxxx and on my behalf, in any way that I would, in the reasonable and sole judgment of RCB be expected to act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity: •  To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. •  The release/indemnification/defense provisions above shall apply to any such decision or action. •  I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. •  The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. •  This power of attorney shall lapse automatically upon completion of the activity listed above that my child is participating in or attending and related activities, and travel if any, and the return of my child to me my designee or my designeeme. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. •  I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: •  List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: •  If any change occurs in the information information, which I have provided with respect to emergency contacts contacts, or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Diocese of Worcester, and I hereby release, indemnify and agree to defend under the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. By signing below I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCB’s agreement to allow my child to participate in this voluntary activity, trip or event, and as an inducement to the RCB to permit such participation, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form Name of my child Date of Birth of my child Complete Address City, State, Zip Code #1 Emergency Contact (other than yourself): Relationship Phone - Work: Home: Cell: Family Doctor’s Name Phone: Child’s Health Insurance Provider Membership Number

Additionally. I appoint RCB as my lawful attorneyYou shall not use an E-in-factISAC Application for commercial purposes or Your own private purposes, to act for me in my name and xxxxx and on my behalfincluding, in any way that I wouldbut not limited to, in the reasonable and sole judgment advertising or promoting a specific product or service, announcements of RCB be expected to act if I were personally presenta personal nature, with respect sharing of files or attachments not directly relevant to the following matters if any injury, illness or medical emergency occurs during the activity: • To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. • The release/indemnification/defense provisions above shall apply to any such decision or action. • I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. • The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. • This power of attorney shall lapse automatically upon completion mission of the activity listed above that my child is participating in or attending and related activitiesE-ISAC, and travel if anycommunication of personal views or opinions, and the return of my child to me or my designee. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. • I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There unless those views are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: • List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: • If any change occurs in the information which I have provided with respect to emergency contacts or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes directly related to the advancement and development mission of the ministry E-ISAC. Unless authorized by an appropriate NERC officer, You are not authorized to speak on behalf of the Roman Catholic Church and E-ISAC or to indicate Your views represent the Diocese views of WorcesterE-ISAC. You must conduct Yourself in a professional manner at all times when using the E-ISAC application. Examples of unprofessional conduct include, and I hereby releasebut are not limited to, indemnify and use of abusive language, personal attacks, or derogatory statements made against or directed at E-ISAC personnel or another Authorized User. You are solely responsible for Your interactions with other Authorized Users. You agree to defend under exercise reasonable precaution in all interactions with other Authorized Users. E-ISAC does not represent, warrant, endorse, or guarantee the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. By signing below I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration conduct of the RCBE-ISAC Application’s agreement Authorized Users. In no event shall E- ISAC or NERC be liable for indirect, special, incidental, or consequential damages arising out of or relating to allow my child any Authorized Users’ conduct in connection with such Authorized User’s use of the E-ISAC Application, including, without limitation, damages, claims, actions, or losses, however arising, from Your use of the Application. If You do not comply with this policy, certain reasonable restrictions on Your use of the E-ISAC application may be imposed, as described below. The E-ISAC has full discretion and authority over all decisions made or actions taken relating to participate violations of this policy and use of the Application. If the E-ISAC determines, upon its own observation or complaint of another Authorized User, that You are not complying with this policy, the E-ISAC may restrict Your access to E-ISAC Applications indefinitely. Before the E-ISAC restricts Your access to an E-ISAC Application, the E-ISAC may first remind You of the obligation to conduct Yourself in a professional manner and in accordance with this voluntary activitypolicy. The E-ISAC reserves the right to inform Your organization of the breach in conduct. At any time, trip the E-ISAC may restrict Your access to an E-ISAC Application, or eventa user community or forum, as may be reasonably necessary to maintain a professional and as an inducement constructive environment for all Authorized Users. You may request removal of the restriction by submitting a request in writing to the RCB to permit such participationE- ISAC. The restriction will be removed at the reasonable discretion of the E-ISAC. If You have concerns about this policy, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form Name of my child Date of Birth of my child Complete Address City, State, Zip Code #1 Emergency Contact (other than yourself): Relationship Phone - Work: Home: Cell: Family DoctorYou may contact NERC’s Name Phone: Child’s Health Insurance Provider Membership NumberGeneral Counsel.

Additionally. I appoint RCB as my lawful attorney-in-fact, to act for me in my name and xxxxx and on my behalf, in any way that I would, in the reasonable and sole judgment of RCB be expected to act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity: • To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. • The release/indemnification/defense provisions above shall apply to any such decision or action. • I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. • The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. • This power of attorney shall lapse automatically upon completion of the activity listed above that my child is participating in or attending and related activities, and travel if any, and the return of my child to me or my designee. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. • I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: • List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: • If any change occurs in the information which I have provided with respect to emergency contacts or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Diocese of Worcester, and I hereby release, indemnify and agree to defend under the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. I agree to follow all state regulations regarding safety during the Covid-19 pandemic as related to outdoor activities. Such regulations will be communicated to us within 48 hours of the event by email by the Office for Youth and Young Adult Ministry of the Diocese of Worcester. By signing below I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCB’s agreement to allow my child to participate in this voluntary activity, trip or event, and as an inducement to the RCB to permit such participation, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form Name of my child Date of Birth of my child Complete Address City, State, Zip Code #1 Emergency Contact (other than yourself): Relationship Phone - Work: Home: Cell: Family Doctor’s Name Phone: Child’s Health Insurance Provider Membership Number

Additionally. ● I appoint RCB as my lawful attorney-in-fact, to act for me in my name and xxxxx and on my behalf, in any way that I would, in the reasonable and sole judgment of RCB be expected to act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity: • ● To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. • ● The release/indemnification/defense provisions above shall apply to any such decision or action. • ● I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. • ● The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. • ● This power of attorney shall lapse automatically upon completion of the activity listed above that my child is participating in or attending and related activities, and travel if any, and the return of my child to me or my designee. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. • ● I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: • ● List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: • ● If any change occurs in the information which I have provided with respect to emergency contacts or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Diocese of Worcester, and I hereby release, indemnify and agree to defend under the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. By signing below below, I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCB’s agreement to allow my child to participate in this voluntary activity, trip or event, and as an inducement to the RCB to permit such participation, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form form: Name of my child child: Date of Birth of my child child: Complete Address Address: City, State, Zip Code Code: Email address: #1 Emergency Contact (other than yourself): Relationship Relationship: Phone - Work: Home: Cell: Family Doctor’s Name Name: Phone: Child’s Health Insurance Provider Provider: Membership Number:

Additionally.  I appoint RCB as my lawful attorney-in-fact, to act for me in my name and xxxxx and on my behalf, in any way that I would, in the reasonable and sole judgment of RCB be expected to act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity: •  To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. •  The release/indemnification/defense provisions above shall apply to any such decision or action. •  I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. •  The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. •  This power of attorney shall lapse automatically upon completion of the activity listed above that my child is participating in or attending and related activities, and travel if any, and the return of my child to me or my designee. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. •  I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: •  List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: •  If any change occurs in the information which I have provided with respect to emergency contacts or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Diocese of Worcester, and I hereby release, indemnify and agree to defend under the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. By signing below I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCB’s agreement to allow my child to participate in this voluntary activity, trip or event, and as an inducement to the RCB to permit such participation, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form Name of my child Date of Birth of my child Complete Address City, State, Zip Code #1 Emergency Contact (other than yourself): Relationship Phone - Work: Home: Cell: Family Doctor’s Name Phone: Child’s Health Insurance Provider Membership Number

Additionally. I appoint RCB as my lawful attorney-in-fact, to act for me in my name and xxxxx and on my behalf, in any way that I would, in the reasonable and sole judgment of RCB be expected to act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity: • To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other first aid and/or emergency actions as our attorney-in-fact shall deem necessary or appropriate for the best interest of my child. • The release/indemnification/defense provisions above shall apply to any such decision or action. • I understand that RCB through its agents will make a reasonable attempt to contact me as soon as reasonably possible in the event of medical emergency involving my child. • The powers and authority granted herein may be revoked prospectively by written notice delivered in-hand to RCB, provided that in such notice I confirm that I am immediately assuming full responsibility for all decisions and actions as to my child’s welfare and health. Absent receipt of such written notice this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. • This power of attorney shall lapse automatically upon completion of the activity listed above that my child is participating in or attending and related activities, and travel if any, and the return of my child to me or my designee. Any revocation of such powers and authority shall not affect any other provision of this Release/Indemnification/Defense Agreement, each of which shall continue in full force and effect. • I understand and agree that RCB is not and shall not be responsible for assuring that my child takes any medication, prescription or otherwise, which may be indicated for my child. There are no medical conditions, nor any life threatening allergies to foods or medicines, that would limit my child’s full participation in the activity or require any special precautions except as I list here: • List any current medications and dosage (prescription and over-the-counter) that the RCB might need to know about should an emergency arise here: • If any change occurs in the information which I have provided with respect to emergency contacts or medical information I shall provide immediate written notification of such change to the RCB. As evidenced by my signature below, RCB and/or an agent thereof may use my child’s portrait or photograph for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Diocese of Worcester, and I hereby release, indemnify and agree to defend under the provisions above the RCB and its agents from any and all liability, loss, damage and expense, including attorneys’ fees, resulting from such use. By signing below I verify that I have carefully read and understand this statement and that I am signing it freely and voluntarily in consideration of the RCB’s agreement to allow my child to participate in this voluntary activity, trip or event, and as an inducement to the RCB to permit such participation, without which it would not do so. I request that my child be allowed to participate in the above-referenced activity, trip or event. Signature of Parent or Guardian Signature of my child Date Telephone - Home: Cell: PLEASE PRINT THE FOLLOWING INFORMATION Name of person signing this form Name of my child Date of Birth of my child Complete Address City, State, Zip Code #1 Emergency Contact (other than yourself): Relationship Phone - Work: Home: Cell: Family Doctor’s Name Phone: Child’s Health Insurance Provider Membership NumberINFORMATION