Documente Academic
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Costa Mesa
Participation Form
Child Name has my permission to participate in the following. Activity on Date Kellys Closet August 25, 2012
I agree to waive all claims against the Kiwanis Club of Costa Mesa (Kiwanis) and hold Kiwanis, its officers, agents and employees, harmless from any and all liability or claims, which may arise out of or in connection with my childs participation in this activity This waiver shall not apply to any occurrences which may arise solely out of the negligence of Kiwanis, its employees or agents.
Signature
Date
Address, City, State, Zip code
WITNESS:
Signature
Date
Phone number
Medical History
Childs Name Address City, State, ZIP Health Insurance Company Group Name on Policy Telephone number or other contact information shown on insurance card Will your child be taking any prescription medication or over-the-counter drugs of any type? If yes, please explain Yes No Policy Number Sex: Age Male Female
Has he/she ever been or currently being treated for Nervousness? Heart Condition? Rheumatic Fever? Headaches? Asthma? Allergies to medication? Yes Yes Yes Yes Yes Yes No No No No No No Convulsion or epilepsy? High Blood Pressure? Cancer or Tumors? Fainting Spells? Diabetes? Other medical conditions? Yes No Yes No Yes No Yes No Yes No Yes No