To the Parents or Guardians of the Participant:
For your child to receive medical care in the event of illness or injury while participating in the USM event, we ask
that you bring a copy of all relevant insurance information for your child with you to the event. We will store it
securely until the end of the program, where we will then return the copy to you.
Is it permissible to provide medical treatment for your child if needed? Ye
s No
Please state any special medical conditions that may require staff attention:
Does your child take medication on a regular basis of which we need to be aware? Yes No
If yes, please explain:
Does your child have any known allergies? If yes, please explain: Yes No.
Is your child under the care of a psychologist/psychiatrist, or being treated for Yes No
any emotional or mental issues?
If yes, please explain:
Are there any restrictions of physical activity that may apply to your child? Yes No.
If yes, please explain:
Yes, I grant permission for my child to be photographed or videotaped during this event. This includes photos
that may be used for promotional or publicity purposes.
I certify that my child has permission to attend the Nights at Thoreau event at USM’s Lake Thoreau Environmental
Center. I release USM from any and every liability, claim, right of action of any kind or nature which my child or legal
representative may have for any and all bodily or personal injuries or property damages or any other damages resulting
there from which might occur during participation in this program and host institution(s), or representative(s) thereof,
and the management or owner(s) of any physical facility in which the program is conducted.
Parent or Legal Guardian’s Name (Print, please): _________________________________________________
Parent or Legal Guardian’s Signature: _________________________________________________________
Date: __________________________
v. of Southern Mississippi
