The Lebanon Lantern The Lebanon Lantern Spring 2019 | Page 14

PERMISSION TO PARTICIPATE
I give my permission for my child to participate in all program activities. He / She is in good health and may participate in
normal program activities unless I specify otherwise.
Emergency Medical Authorization & Release / Indemnification
In the event a medical emergency should arise while my child is attending the Lebanon Borough Recreation Program, and
I and/or my spouse cannot be contacted, or there is not time to do so, I have the right and do hereby authorize and delegate
to the Lebanon Borough Recreation Program Director, and grant her / him Power of Attorney to sign on my behalf for my
child all necessary or required medication authorizations, releases, or other medical documents, and I do hereby release
and indemnify the Lebanon Borough recreation Program, The Borough of Lebanon and the Lebanon Borough Public School,
as well as its employees, principals, agents or assigns from any and all claims, or damages relating to such actions
undertaken on my child’s behalf.
Parent / Guardian Signature: _________________________________________ Date:_______________
Name of Family Physician: _________________________________ Phone: ______________________
Name of Family Dentist: ___________________________________ Phone: ______________________
Please be aware of the following medical concerns regarding my child / children:
Child #1 First and Last Name: ______________________________________________________________
Allergies or Medical Concerns: ___________________________________________________________
_____________________________________________________________________________________
Child #2 First and Last Name: ______________________________________________________________
Allergies or Medical Concerns: ___________________________________________________________
_____________________________________________________________________________________
Child #3 First and Last Name: ______________________________________________________________
Allergies or Medical Concerns: ___________________________________________________________
_____________________________________________________________________________________
Child #4 First and Last Name: ______________________________________________________________
Allergies or Medical Concerns: ___________________________________________________________
_____________________________________________________________________________________