Medical Release Form - The Aleph Institute - N.E. Regional Headquarters

The information below must be provided completely. If your medical or insurance information changes, please contact the Aleph Institute or submit another online form to update your information.

How many children are you signing for?*

Child's Name*

First Name Last Name

Date of Birth*

Month Day Year

School*

Allergy and Health Info*

None

1st Child's Name*

First Name Last Name

1st Child's Date of Birth*

Month Day Year

1st Child's School*

1st Child's Allergy and Health Info*

None

2nd Child's Name*

First Name Last Name

2nd Child's Date of Birth*

Month Day Year

2nd Child's School*

2nd Child's Allergy and Health Info*

None

3rd's Child's Name*

First Name Last Name

3rd Child's Date of Birth*

Month Day Year

3rd Child's School*

3rd Child's Allergy and Health Info*

None

4th Child's Name*

First Name Last Name

4th Child's Date of Birth*

Month Day Year

4th Child's School*

4th Child's Allergy and Health Info*

None

5th Child's Name*

First Name Last Name

5th Child's Date of Birth*

Month Day Year

5th Child's School*

5th Child's Allergy and Health Info*

None

Home Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I hereby give my permission, for myself or my child, to participate in an activity organized by the Aleph Institute. I hereby release, hold harmless and absolve the Aleph Institute, their officers, staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations,singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Aleph Institute staff or any adult counselor acting on behalf of Aleph Institute with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate} licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child's medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that the Aleph Institute may tape or photograph my child and record his or her Voice during their participation in the activity. I agree that the Aleph Institute will be able to use them, in whole or in part. whether In original or modified form in any manner or media, including without limitation, for the purpose of advertising, promoting, and publishing the Aleph Institute whether doing the activity or thereafter. I hereby release and discharge the Aleph Institute and an affiliated entities from any and all claims, demands, or causes of action that I shall in connection with the use and exercise of the rights granted in this release.

I agree to the above terms*

Yes

Parent/Guardian Name*

First Name Last Name

Relation to child*

Parent

Cell Phone Number*

Work Number

Home Phone Number

Emergency Contact (If parents cannot be contacted)*

First Name Last Name

Emergency Contact Phone Number*