Cf6.cdr

PERMISSION TO ATTEND THE ALL AFRICA STUDENT CONVENTION AND
PERMISSION FOR MEDICAL TREATMENT AND RELEASE OF LIABILITY FOR A MINOR
Please type or print clearly. Please complete all applicable fields in full.
General Information
Student Name ________________________________________ Date of Birth _________________________________________ Cellphone No ______________________________________ Home Address _____________________________________________________________________________________________ School Information
School ___ ___________________________________________________________________ School Phone _________________________________________ School Fax ___________________________________________ School Email _______________________________________________________________________________________________ School Address ____________________________________________________________________________________________ Parent/Guardian Information
Father’s Name ________________________________________ Mother’s Name _______________________________________ Father’s Cellphone_____________________________________ Mother’s Cellphone ____________________________________ Guardian’s Name ______________________________________ Relationship to student _________________________________ Guardian Cellphone____________________________________ Home Email __________________________________________ Home Phone _________________________________________ Home Address (if different from student) ____________________________________________________________________________ Alternative Emergency Contact (not parent or guardian)
Alternative Emergency Contact Person___________________________________________________________________________ Home Phone_________________________________________ Cellphone ____________________________________________ Medical Information
Name of Physician___ __________________________________ Physician Contact No_______________ ____________________ Medical Aid Provider____________________________________ Medical Aid Member No_________________________________ Medical Aid Contact No_______________________________________________________________________________________ Allergies___________________________________________________________________________________________________ Please list any special medical conditions and treatment required for these conditions ____________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ PLEASE NOTE: Should you have a special medical problem or any allergies, an identifying bracelet should be worn.
PERMISSION TO ATTEND THE ALL AFRICA STUDENT CONVENTION AND
PERMISSION FOR MEDICAL TREATMENT AND RELEASE OF LIABILITY FOR A MINOR
(CONTINUED)
Please type or print clearly. Please complete all applicable fields in full.
I, __________________________________________________(guardian), hereby give permission for my ____________________________________________________(student), to attend the All Africa Student Convention hosted by Accelerated Christian Education (South Africa) in Bloemfontein during September/October 2013. He/she will be under the supervision of ___________________________________________________ (sponsor name).
I do also hereby grant permission for Accelerated Christian Education (South Africa) to use any photographs taken of my child during I, __________________________________________________(guardian), hereby give permission Accelerated Christian Education (South Africa) to obtain medical treatment for my daughter, ______________________________________(student) while in attendance at the All Africa Student Convention in Bloemfontein during September/October 2013.
I understand that I am responsible for accident and medical insurance if needed en route to and from the convention and throughout the duration of the convention. I herewith release Accelerated Christian Education (South Africa) and the University of the Free State from any liability for death or injury that may result from my child’s voluntary participation in any activity while at and en route to and from the All Africa Student Convention.
My child may be given the following if needed: Signature _____________________________________________ Date ________________________________________________ PLEASE NOTE: Should you have a special medical problem or any allergies, an identifying bracelet should be worn.

Source: http://www.aceministries.co.za/ckfinder/userfiles/files/CF6_2013.pdf