Name__________________________________
Address________________________________
Home Phone____________Bus. Phone________
Friend/Relative to be notified if parent cannot be
reached:
Name__________________________________
Relationship____________Phone____________
Address________________________________ |
Date of
Birth____________Age_____________
Parents or Guardians_____________________
Class Selection__________________________
Day____________Time___________Amount Enclosed________________
|
Height______Weight_______Allergies__________________Current
Medication________________
Operations or Serious Illness__________________
Preferred Physician________________________Phone
#__________________RELEASE:
I hereby consent to have my child/ward participate in
programs offered by the Delco Training Center Inc. It is
hereby agreed that I, my child(ren) adopted or otherwise,
my executors or heirs, waive and release all rights and
claims for damages that I may have at any time. The risks
in respect to such a program are fully understood. This
release is valid any and all sessions.
PERMISSION FOR MEDICAL TREATMENT:
I confirm that the above named person is in good health.
I hereby authorize and consent to simple first aid, x-ray
exams, anesthetic, medical or surgical diagnosis or
treatment and hospital care.
REFUNDS: I
understand that all fees and deposits are nonrefundable
or transferrable.
SIGNATURE
(PARENT/GUARDIAN)______________________________DATE____________
|
