Medical Release Form - Model United Nations

A. STUDENT INFORMATION (Please print)

Today’s Date ______________

Last Name ____________________________ First Name ____________________ MI _________

B. EMERGENCY MEDICAL SERVICE

If medical action or treatment is required and the parent(s) or guardian(s) cannot be reached, I/we hereby consent for our student
to be given medical care (including calling for ambulance services at the parents’ cost) by the doctor or hospital selected by the
school. PLEASE WRITE ON THE BACK OF THIS SHEET ANY MEDICAL INFORMATION THEY MIGHT ASSIST IN CASE OF
AN EMERGENCY, INCLUDING, BUT NOT LIMITED TO ALLERGIES, PAST MEDICAL HISTORY AND MEDICATIONS.

C. CONTACT INFORMATION

Parental Contact:
Name:
Relationship:
Mailing Address:
Phone Number (H) (W) (C) (Other)

Parental Contact:
Name:
Relationship:
Mailing Address:
Phone Number (H) (W) (C) (Other)

Additional Emergency Contact:

Name:
Relationship:
Mailing Address:
Phone Number (H) (W) (C) (Other)

D. WAIVER OF LIABILITY
I/We release and waive, and agree to indemnify, hold harmless or reimburse Helena Public Schools, and the individual
members, agents, employees and representatives thereof, as well as activity supervisors, from and against any claim which the
above named student, I/we, and other parent or guardian, and siblings, or any other person, firm or corporation may have claim
to have known or unknown, directly or indirectly, for any losses, damages or injuries arising out of, during or in connection with
the above named student. The above waivers are extended to the fullest limits provided by law.

E. CHEMICAL USE/ILLEGAL ACTIVITIES POLICY

I/We understand that any illegal activity or use of unauthorized chemical substances can lead to the immediate removal of the
above named student. Any activity that endangers any student, member of the staff, or any third party will lead to the immediate
notification of relevant law enforcement and the immediate withdrawal of the above named student from the activity.

F. REVIEW OF RULES
I/We understand and agree to abide by the rules and procedures stated on the “Rule of the Road” document. I/We also
understand that the above students must adhere all school, district and organization policies.

SIGN (X)____________________________________________________ DATE ____________________

Parent/Guardian Signature

SIGN (X)____________________________________________________ DATE ____________________

Student Signature