PARENT PERMISSION SLIP MEDICAL TREATMENT AUTHORIZATION ALL- NIGHT LOCK-IN Fill in the form below and bring it with you. Antelope Lanes 6301 E 2nd St, Prescott Valley, Arizona 86314 Phone: 928-772-7501 or 928-772-7331 Fax: 928-772-4277
I hereby give permission for my child __________________________________ , to participate in the Antelope Lanes All-Night Lock-In. (Please complete a separate form for each child.)
In the event of injury, illness or emergency, I hereby authorize Antelope Lanes, and/or its agents and employees to secure medical care and treatment for my child, including, but not limited to x-ray, examination, anesthetic, medical, dental, or surgical diagnosis or treatment and/or hospital care as deemed reasonable necessary for the safety and welfare of my child. I agree to assume financial responsibility for any resulting medical charges.
Please circle A or B below:
A My child has no special problems or medical needs of which the staff should be aware.
B My child is in need of special care:
Medication:
Other:
Food or drink my child should not receive:
My child is allergic to:
I fully understand that my child is required to follow all rules and requirements governing conduct during the lock-in. I hereby acknowledge that if my child is determined to be in violation of these behavior standards, he/she will be sent home.
I, the undersigned, hereby agree to release, hold harmless, indemnify, and waive all claims against Antelope Lanes, its related companies, and/or its agents and employees for any claims, law suits, and/or demands, in any way, relating to or arising from my childs presence on the premises.
Date: ____________ Parent or legal guardian: ______________________________________