Parental Permission and Medical Authorization Form

PARENTAL PERMISSION AND MEDICAL AUTHORIZATION FORM

Parent(s)/ Gaurdian: ______

Current Address: ______City: ______State: ______Zip Code: ______Phone Number: ______

Participant Name: ______Birth date: ______

Religious Name: ______

I give permission for my child (named above) to attend the events, field trips, and service projects associated with the Youth Group Minh Quang. I further give permission for my child to be transported to and from events by hired and volunteer drivers authorized by Youth Group Minh Quang.

Member Fee:

Monthly Fee: $9

Yearly Fee: $75

I further give permission for my child to participate in all activities sponsored by the Youth Group Minh Quang, except as noted: ______

______

Signature of Parent or Legal GuardianPrinted name of Parent or GuardianDate

EMERGENCY CONTACT INFORMATION

Parent(s)/Guardian(s) / Phone Numbers / Relationship
Name
Street Address
City / State / Zip
Parent(s)/Guardian(s) Email address(es)
Email address(es)

Health Care Information

Participant Name: ______Birth date: ______

Please list any allergies to drugs, foods, plants, insects, etc: ______

______

Please list any prescription medication to be taken by the participant (including what it is taken for, when it is to be taken, dosage information, and any special procedures):______

Please list any additional information relevant to participating in Youth Group activities (dietary needs; surgeries or serious injuries; chronic or recurring illness; medical conditions such as epilepsy or diabetes; psychiatric counseling or indications, etc.): ______

You have received this parental consent form to both inform you and to request your permission for your child’s photo/image and name to be published on and/or any other websites maintainedand/or administrated by Minh Quang Youth Group. The law requires that we ask for your permission to use information about your child. Following the law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes members’ names, age, grade, and photo or image. If you, as the parent or guardian, wish to cancel this agreement, you may do so at any time in writing by sending a letter to the Youth Group Federation, Tam Nguyen and the Youth Group Deputy Federation, Thanh Nguyen, and such cancellation will take effect upon receipt.

Check one of the following choices:

______I/We give permission for this youth’s photo/image and all other personal identifiers listed above to be published on theMinh Quang Youth Group public website or any site operated byMinh Quang Youth Group.

______I/We give permission for only a photo/image that includes this youth without any other personal identifiers to be published on the Minh Quang Youth Group public website or any site operated by Minh Quang Youth Group.

______I/We do not give permission for photo/image that includes this youth to be published on the Minh Quang Youth Group public website or any site operated by Minh Quang Youth Group.

Gia Đình Phật Tử Minh Quang

Tâm Nguyễn, Liên Đoàn Trưởng and Thành Nguyễn, Liên Đoàn Phó

8318 SE Harney St. Portland, OR 97266

Tâm (503) 432- 9363 or Thành (503) 432- 3452