Permission Form - Lifecyclesla

Parent/Guardian Medical Release and Permission Form

The purpose of this form is to provide permission to participate in the LIFECYCLES bicycling and mentoring program. During this program, we will ride under trained supervision in St Tammany and nearby parishes, attend group recreational activities and participate in community service projects. Bicycles, gear, uniforms and meals are provided free of charge.

Teen's name

First

Last

Teen's date of birth

Street Address

Please fill in your complete mailing and/or physical address.

City, State, Zip Code

What grade is he in?

If between grades, list the grade they will be in at the start of the next school year.

Teen's Height

Given in Feet and Inches

Below Number List

Teen's Head Circumference (Inches)

Needed for helmet sizing

Parent/Guardian Name

First

Last

Parent/Guardian Email

Parent/Guardian Phone

XXX=XXX=XXXX

Second Parent (or other Emergency Contact Person) Full Name

Second Parent or Emergency Contact Email Address

Second Parent or Emergency Contact Phone Number

XXX-XXX-XXXX

List all prescription medications the teen uses (with dosage)

List NA if none

List any physical disabilities or limitations

Any known allergies or reactions

Medical Insurance Information

List Company and Policy Number

Permission & Agreement

I agree and give my permission

In an emergency, illness, injury, or accident requiring medical attention, I give my permission to LIFECYCLES leaders, its representatives, and all attending health care professionals for my child to administer medical treatment, to hospitalize, anesthetize, or perform surgery. I understand that every effort will be made to contact before these actions are taken. In addition, I do release, acquit, discharge damages or liabilities arising from the treatment of any illness, injury, or accident incurred during my child’s participation in these activities. It is the intention of this release that the above LIFECYCLES leaders and representatives incur no liability while attempting to meet all medical needs that my child may require during these activities. I agree to the following:
- I am legally responsible for the above identified participant.
- I grant full permission to participate in these activities.
- I grant permission to use photos or videos of my child LIFECYCLES promotions, printed material and social media.
- I agree to the release described above.

Type Your Name Below to Sign this Form