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Rise Above Medical Form

  1. Disclaimer*

    In submitting this form with your email address you are giving acceptance for parental release.

  2. Sex

  3. Statistic use only. All information is confidential.

  4. Race/Ethnicity

  5. Family

  6. Medical Information

  7. Do you have any of the following (check all that apply)?

  8. Is there anything that could affect your child’s experience in the program that we should be aware of, i.e. medical concerns, allergies, physical or social limitations, etc.?*

  9. Emergency Contacts (Including Parents)

  10. All of the above information was provided or approved by me and is deemed to be true and accurate. I hereby give my permission for the registered child to participate in the above indicated program through the Town of Ellington Youth Services.

  11. Photo Release

    Photos/Videos may be taken at this event that could appear on the Youth Services website or Facebook page or Rise Above Facebook page with no names listed. I give permission for my child to be photographed. I understand no names will be published.

  12. Medical Authorization - (Optional)

    In all cases requiring emergency treatment, I hereby give my permission to the Ellington Youth Services staff and the Town of Ellington or his/her designee to select a physician for the registered child, if I cannot be reached. I further authorize the physician to proceed with an examination, investigation and hospitalization, necessary treatment of any injury and/or illness and operation if needed. I also understand that the Town of Ellington does not provide accident or health insurance.

  13. Leave This Blank:

  14. This field is not part of the form submission.