Appalachian Teen Trekkers, Inc. Parental Consent Form

Participant’s Name ___________________________________

Parent’s Name(s) ___________________________________Phone(h)_____________(w)________________________________________________Phone(h)_____________(w)_____________

Emergency Contact:_________________________________Phone(h)_____________(w)_____________

Insurance Company Name __________________________________________

Liability ReleaseAs the Parent/Legal Guardian of the above-mentioned participant, I hereby give my consent forparticipation in the Appalachian Teen Trekker program(s). I understand that although all programs will be led by competent, trained, adult staff & volunteers, utilizing all the necessary safety precautions, there still remains an inherent risk of injury and/or loss of life resulting from participation in these programs.

Acknowledgement of RiskI assume all risks and hazards incidental to such participation, including transportation to andfrom the program, and hereby waive, release, and agree to hold harmless Appalachian Teen Trekker, its employees, its volunteers, and any sponsoring agency for any claims arising out of any loss or injury that the participant might sustain while engaged in this program.

Permission to transport and administer care in the event of an emergency in which my child must be taken to the hospital for treatment, I hereby give permission to transport my child and for hospital staff to begin treatment immediately.

By signing below I am stating that I have read understand the liability release, acknowledgement of risk, and permission to transport and administer care paragraphs above.

________________________________________Signature of Parent/Legal Guardian if under 18

_______________Date

____________________________________Signature of Participant

_______________Date

Participant Health Information

Participant’s Name _________________________________________

Birth date ____________________________________

Date of last Tetanus Booster Immunization ________________________________

Medication(s) taking _______________________________________________________________

Dosage(s) __________________________Time to be administered_________________________

Any adverse reactions to drugs/medications?(Penicillin? Aspirin?) ______________________________ ____________________________________________________________________________________

Is participant a sleepwalker?_________________________ Asthmatic?_________________________

Does participant have allergies? use an inhaler? (please Describe) _________________________________________________________________________________________________________________

Has participant ever had any previous allergic reaction to bee stings, foods, dust, etc? (Please describe)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does participant have a history of seizures?__________________________________________________

Has participant ever slept away from home?_________________________________________________

Please list any physical restrictions, previous medical conditions, operations, etc. that might affect participation. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Can participant swim? (CIRCLE ONE)     Good Swimmer        Can Swim         Non Swimmer

Does participant get carsick? ________________________________________

Other factors we should be aware of to care for your child: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Height_______________ Weight ____________

_________________________________________Signature of Parent/Legal Guardian if under 18

____________Date