Emergency Contact, Medical Info, and Releases

Emergency Contact, Medical Info, Liability Waiver

Step 1 of 2

Child(ren)'s Name(s)*
To add additional children, click the plus sign on the right. Please include a preferred name or nickname for children when applicable.
Name Date of Birth Gender School
Child(ren) Lives With*
Parent / Guardian
If parents are divorced or separated, please specify custodial parent.
First Parent/Guardian*
At least one phone number and email required.
Name Relationship to Child Work Phone Cell Phone Email
Second Parent/Guardian
At least one phone number and email required.
Name Relationship to Child Work Phone Cell Phone Email
Emergency Contacts
Please list two relatives or nearby neighbors that you have notified and who have agreed to assume temporary care of your child if you cannot be reached.
Emergency Contact #1*
Phone number required
Name Relationship Phone
Emergency Contact #2*
Phone number required
Name Relationship Phone
Authroized to Pickup
Please list all persons that you authorize to pickup your student from afterschool.
Authorized Individual #1*
Phone number required
Name Relationship Phone
Authorized Individual #2
Phone number required
Name Relationship Phone
Authorized Individual #3
Phone number required
Name Relationship Phone
Authorized Individual #4
Phone number required
Name Relationship Phone
Code Word*
Please select a code word that you will share with those persons authorized to pick up your child(ren). The code word and/or proof of identification (driver’s license) may be asked for at pickup time.

Medical Information
Doctor & Insurance*
If insured, please include insurance information.
Doctor's Name Doctor's Phone Child's Weight Child's Height Medical Insurance Company Medical ID No.
Medications
If your child routinely takes medication, please fill out the following, even if the medication is not dispensed during Mountain SOL programs. Any medication needed during the program should be given to a designated staff member and will be dispensed by the designated staff member.
Please list the following information for each medication (click on the plus sign on the right to add medications).
Medication Dosage/How Often Prescribing Doctor
Medical Authorization*
- I authorize staff to assist in the dispensing of medication including epi-pen and inhalers, as prescribed above
- My child does not require medication
Sunscreen & Insect Repellent Authorization*
Since we are outdoors, sunscreen and insect repellent are important for your child's protection. We need your permission to use sunscreen and insect repellent on your child. If you do not authorize Mtn SOL, please provide your child with their own sunscreen and insect repellent.
- Yes, I authorize the use of sunscreen and insect repellent.
- No, I do not authorize the use of sunscreen and insect repellent.
Additional Health Information*
Important: Please describe any special health considerations including, but not limited to ALLERGIES or physical conditions that may affect your child's participation in our programs (please list "none" if this does not apply). Please be specific about any allergies the child has and if the allergy requires an Epi-Pen (or similar).
Additional Child Information*
Please describe any behavioral or circumstantial issues that staff should be aware of that may affect your child's participation in our programs. Are there certain things that would be helpful to know about your child? Likes/dislikes, change in family circumstances, fears, etc (or note "None").
Medical Form & Permission to Treat*
My child is in good physical and mental health. I have listed any special health considerations. I acknowledge that acceptance of my child to the program with my child's special health considerations is at the discretion of Mountain SOL School. In case of emergency, I understand that every effort will be made to contact parents or guardians of children. In the event I cannot be reached within a reasonable time, I grant permission to the physician selected by Mountain SOL staff to hospitalize, secure treatment for and to order injection, anesthesia or surgery for the child as named herein.
- By checking this box, I hereby certify that the above information is correct.
Release of Liability and Hold Harmless*
I authorize my child to participate in the program and any associated transportation services provided by Mountain SOL School or its agents.

I acknowledge that I am the only one who can determine if I or my child is physically fit enough or adequately skilled enough to participate in the program. I acknowledge the inherent risks that may result from by child’s participation in the program including falls, fractures, contraction of infectious diseases, misbehavior of other children, etc., all of which may result in injury or death to my child or damage to his/her/our property. I further acknowledge that Mountain SOL School is neither a common carrier nor in the business of providing transportation services to the public. I expressly assume these risks and any associated costs, damages or losses, including those caused by simple negligence of Mountain SOL School, and waive and fully release all claims held by me, my spouse/partner, my child or any of our estates from and against Mountain SOL School and its agency partners, officers, board members, agents, employees, volunteers and representatives, arising from my child’s attendance and participation in the program and accept full responsibility for the cost of all medical treatment to my child as a result of any injuries caused by or through such other risks.

This waiver and release will apply to any and all actions, causes, damages, claims or demands of any kind, whether known or unknown, arising out of or otherwise incidental to participation in the program.

I further agree, on behalf of myself and/or my child, to indemnify, defend and hold harmless Mountain SOL School and its agency partners, officers, board members, agents, employees, volunteers and representatives from any injuries, liabilities, claims, damages and expenses, including attorney fees, incurred by Mountain SOL School, me, my child or on behalf of my child, arising from my child’s attendance and participation in the program, with the exception of gross negligence or reckless misconduct of Mountain SOL School.

While participating in the program, I and my child will obey all rules, regulations and laws of the State of West Virginia and the United States. I and my child will further obey all rules, regulations and policies of Mountain SOL School associated with the program. I acknowledge that my or my child’s failure to comply with these rules, regulations, policies and laws may result in my or my child’s expulsion from the program.

I agree that this release will be governed by the laws of the State of West Virginia. If any provision of this release is found to be invalid or unenforceable, then the remainder of this release will have full force and effect, and the invalid provision will be modified, or partially enforced, to the maximum extent permitted by West Virginia State law.
- By checking this box, I hereby certify that this information is correct. I have read all of the above terms and conditions, and I understand and agree to be bound by them.

Doctor's Name	Doctor's Phone	Child's Weight	Child's Height	Medical Insurance Company	Medical ID No.

Name	Date of Birth	Gender	School

Name	Relationship to Child	Work Phone	Cell Phone	Email

Name	Relationship to Child	Work Phone	Cell Phone	Email

Medication	Dosage/How Often	Prescribing Doctor

Emergency Contact, Medical Info, Liability Waiver

Step 1 of 2

Parent / Guardian

Emergency Contacts

Authroized to Pickup

Medical Information