All participants under the age of 18 need a permission form/liability waiver signed by a parent/guardian. All participants under the age of 16 must also be accompanied by an adult. Additionally, the student must be mature enough to discuss health and death.

Permission Form Request

Parent / Guardian Name

First Name

Last Name

Parent / Guardian Email Address

Parent / Guardian Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian Phone Number

(###)

###

####

Student Name

First Name

Last Name

Student Age

(student age by date of class)

Student Date of Birth

MM

DD

YYYY

Student Allergies

Student Medications

Student Conditions

Emergency Contact Name

First Name

Last Name

Emergency Contact Relation

Emergency Contact Phone Number

(###)

###

####

Course Title

Class Date

MM

DD

YYYY

Additional Information

Questions, Comments, Concerns

I _____[Parent/Guardian]_____, the parent or legal guardian of _____[student]_____ (“my child”), give permission for my child to attend _____[event]_____.

I understand that personal injury can and may occur to my child, and I hereby authorize Stephen Shoults or an appointee to seek and consent to emergency medical attention for my child as needed; and I further agree to be liable for and to pay all costs incurred with such medical attention.

I hereby release Keystone Community Rescue LLC, its employees, agents and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in or traveling to and from this event.

I give permission for my child to ride in any vehicle designated by Keystone Community Rescue LLC, its employees, agents and volunteers, while participating in and traveling to and from this event.

I agree to accept full responsibility, financially or otherwise, for any damage my child may do to the property of Keystone Community Rescue LLC, properties visited on outing, other’s personal property, or vehicles used for transportation.

(Parent/Guardian agrees to the above; a copy will be sent to you)