Medical Release & Youth Activities Consent Form

Please fill out a form for each child ages 0-18 who will participate in the ASI convention meetings and offsite activities. You will also need to print it and bring it to the youth registration desk at check-in.

Child Information

First Name *

Last Name *

Age *

Hair Color *

Eye Color *

Height *

Weight *

Parent or Guardian's Information

Name of Parent of Legal Guardian *

Phone Number *

Address *

City *

State *

Zip/Postal Code *

Country *

Parent/Guardian's Convention Hotel *

Parent/Guardian's Hotel Room Number *

Please PRINT names and cell phone numbers of parents attending convention who will be available for immediate contact. Include one
non-parent contact as well, if possible. (Please leave cell phones on vibrate mode in case we need to contact you.)

Contact Person 1 *

Relationship

Onsite Cell Phone *

Contact Person 2 *

Relationship

Onsite Cell Phone *

Contact Person 3 *

Relationship

Onsite Cell Phone *

Health Information

Please list any medical conditions your child may have (such as Diabetes, Epilepsy, Asthma, etc.)

Allergies

Food

Medication

Insect bites/sting

Other

Child's Allergies

List any physical conditions that may limit participation in activities

Last Tetanus immunization date

Special Dietary Needs:

Activities Permission & Medical Release *

I hereby give permission for my child to attend and participate in onsite and offsite activities planned by the ASI Youth Convention leaders. In case of an emergency or illness, I hereby give permission to the hospital and/or physician selected by ASI leadership to hospitalize, treat, provide anesthesia or surgery for my child.

Health Insurance Company

Policy #

Photo Model & Video Release *

I hereby grant permission and authorize ASI the irrevocable right to use, reproduce, and publish any/all photographs and videos taken of me or my minor child during convention, and our names, for use for all purposes in any form, printed or electronic. I understand that such photographs and video recordings of me or my child may be placed on the internet. I release ASI from any expectation of confidentiality for the above signed minor child and myself and attest that I am the parent or legal guardian of the child listed above and that I have authority to consent and allow ASI to use their photographs, videos, and names. I acknowledge that since participation is voluntary, neither the minor child nor I will receive any financial compensation. I agree that participation in any publication and/or website produced by ASI confers no rights of ownership to me whatsoever and I waive the right to approve the final product. I release ASI and its representatives from liability for any claims by me or any third party in connection with my participation or the participation of the above named minor child. All photos and videos shall remain the property of ASI. This release is binding on me and my heirs, assigns and personal representatives.

Signature

Clear

Child's Photo

Maximum file size: 268.44MB

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