Please print
Name: ________________________ Date of Birth:__________________
Address:____________________________ Telephone:____________________

School:_____________________________ Grade (Fall 08):________________

Mother’s Name:______________________ Business Phone:________________
Father’s Name:_______________________ Business Phone:________________

Person to contact if parents cannot be reached:_______________________________
Relationship to child:__________________ Telephone:______________

Are there limiting factors which could restrict your child’s normal participation? Yes No
If yes, please specify:

Please tell us about your child’s swimming ability_______________________________

Does your child have any allergies that you are aware of? Yes No
If yes, please specify:

May ADAPT use photos in which your child appears? Yes No

I hereby pledge for myself, my heirs, executors or administrators, to waive and release all rights and claims for damages I may have against ADAPT. I also release this organization’s agents, assigns, or officials for any and all injuries suffered by my child.

Should my child be taken to the hospital for emergency purposes, I hereby grant permission to the attending physician and staff to treat my child, ____________ for anesthesia, medical, x-ray, and surgical procedures as may be deemed necessary or advisable.

I understand that in an emergency, an attempt will be made to communicate with me prior to use of this permission.
For hospital information ONLY: Our doctor’s name ___________________________________ Doctor’s telephone:______________________
Medical insurance:_______________________ Policy #:______________________________ Subscriber:_____________________________

By signing this permission slip I understand and consent to a routine search of my child's possession's to be conducted by ADAPT, Inc. staff. In the event that contraband is found on your child or in your child's possessions it is understood that ADAPT, Inc. staff will contact the individual's parents and the local law enforcement.

Signature of parent/guardian:______________________________ Date:________________

Signature of student:____________________________________ Date:________________

*Please feel free to contact Sean O'Brien at 603-236-9227 or sobrien@linwood.k12.nh.us if you have any questions.