WAIVER

Name of Event: _____________________________________________________________________

Date: _________________________
Name: _____________________________________________________________________________
Region & Local Chapter: ____________________________________________________________

EMERGENCY INFORMATION:
Contact Person 1: ___________________________ Contact Number: _____________________
Contact Person 2: ___________________________ Contact Number: _____________________
MEDICAL INFORMATION:
List all the ailments your child suffer from:

_____________________________________________________________________________________
List any medication your child might need:

_____________________________________________________________________________________
Indicate any allergies with certain medications:

_____________________________________________________________________________________

I take responsibility for my child’s whereabouts after this activity.

I agree to waive, release, indemnify and hold harmless the NFJPIA-Region IV, its officers,
members and all the organizers of this event from any claims of liability arising out of my
child’s participation in this activity. I also agree to waive that NFJPIA-Region IV, its
officers, advisers, members and all organizers of this event have 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 above Printed Name Date