Event:_______________________________________

Date:____________________________________________

MEDICAL RELEASE/CODE OF CONDUCT

Participants Name_______________________________________________________

Who to call in case of an emergency__________________________________________

Telephone number_______________________________________________________

Please explain any restrictions or limitations affecting participation in the activity.

Be specific__________________________________________________________

Any allergies?_____________Be specific_________________________________

____________________________________________________________________

Is any special medication required? If yes, please explain_________________________

AUTHORIZATION: Permission is granted for treatment of minor injury or illness. In event of an emergency and I cannot be reached, I hereby give permission for the adult in charge to seek professional medical help and transport my child.

Health Insurance Company______________________Policy #_______________

CODE OF CONDUCT
1. I will not smoke, drink alcoholic beverages (this includes beer), or use illegal controlled substances nor will I have in my possession any of the same during this activity.
2. I will follow the scheduled program of activities and cooperate fully with the evening activity rules.
3. I will cheerfully participate in all activities with an open and inquiring mind. 
4. I understand that if I do not adhere to this code of conduct, I will forfeit participation in the event. I understand this means my parent/guardian will be called and will be required to pick me up at the event at that time.

Signature of Participant_______________________________Date___________________

Signature of Parent/Guardian___________________________Date___________________