Form Universal Permission For Year 2023-2024 CHILD'S INFORMATION Name School Grade Male Female DOB Home Address PARENT/ GUARDIAN INFORMATION Name Email CONTACT DETAILS Name Phone Number Name Phone Number EMERGENCY CONTACT Name Relation Name Relation Name I, am the legal guardian of (child’s name (“Participant”), and grant permission of (child’s name (“Participant”), and grant permission to him / her to attend and participate fully in YOUTH CIRCLE , ICCP Sunday School / ICCP Quran Class / ICCP Events / Retreats during the year 2022 To 2023 LIABILITY RELEASE: In consideration of ICCP allowing the Participant to participate in these ICCP children/youth programs, I, the undersigned, do hereby release, forever discharge and agree to hold harmless ICCP, its administrators, directors, employees, volunteers and teachers (collectively herein the “ICCP”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death or damage as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify ICCP for any liability sustained by ICCP as the result of the negligent, willful or intentional acts of the Participant, including financial loses. Initials: MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization. Initials:. : PHOTO RELEASE: I grant permission to ICCP to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the activities at ICCP. Initials: : OVER-THE-COUNTER MEDICATION PERMISSION: Do you give permission for your child/youth to be given over- the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at an ICCP event? No. Contact me or get medical help if my child has any minor medical concerns. Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions. Name of parent/Guardian Guardian Date Send
