2009 SADD NATIONAL CONFERENCE

STUDENT CONFERENCE PARTICIPATION FORM

Contact Information.  Please provide full legal name.

Last Name:   First Name:     Name for Nametag: 

Male  Female   T-Shirt Size:  S  M  L  XL  XXL  Other:  I prefer vegetarian meals.   

School:      Conference Group Leader :      

Grade in Fall 09:

  Home Street Address: 

City: State: Zip: 

Home Phone:  E-Mail Address: 

Custodial Parent/Guardian

Name:   E-Mail Address: 

Home Street Address: 

City: State: Zip: 

Home Phone:  Work Phone:       Cell Phone: 

Second Parent/ Guardian Name

Name:  E-Mail Address: 

Home Street Address: 

City: State: Zip: 

Home Phone:  Work Phone:  Cell Phone: 

Emergency Contact [If parent(s) cannot be reached]

Name:  Relationship: 

Home Phone:  Work Phone:  Cell Phone: 

Medical Information (confidential - to be used only in case of emergency)

Name of Health Insurance Provider: 

Policy/ID/Subscriber Number: 

Group Number (if applicable):  Insurance Provider Phone: 

Primary Care Physician (PCP):  

PCP Office Phone: 
Date of Birth: Social Security Number:

Please list any medications taken; medication, food, or other allergies; dietary restrictions; or other medical condition:

 

The parent/guardian signature below indicates that you have read and approved the following:

I have reviewed the information and authorize my child to attend the SADD National Conference. I give my permission for my child to take part in activities, including recreational and social activities that may include community-service projects and other activities. I will not hold SADD, Inc. or WorldStrides responsible for accident or illness incurred or damage to or theft of personal property, and I waive any claims against SADD, Inc. or WorldStrides except for claims arising from gross negligence or willful acts by SADD, Inc., WorldStrides, or their agents. The health information on this form is accurate to the best of my knowledge. I give permission to SADD, Inc. or WorldStrides to perform routine health care for my child, including dispensing over-the-counter medication or medication prescribed to my child. While I understand that every attempt will be made to reach me in the event of an emergency, if no parents/guardians or emergency contacts can be reached, I give permission for SADD, Inc. or WorldStrides to seek emergency care, including emergency transportation, and for the physician secured by SADD, Inc. or WorldStrides to secure and administer treatment, which may include hospitalization, x-rays and routine tests, injections, anesthesia, surgery or other treatment for my child. I understand that my personal/family health insurance will be billed for such treatment, and I agree to pay any related expenses. I authorize the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that SADD, Inc. and WorldStrides be treated as acting in loco parentis. Further, it is my intention that the representatives of SADD, Inc. or WorldStrides be treated as “personal representatives” for the purposes of disclosing protected health information subject to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510(b)) to the disclosure to SADD, Inc. or WorldStrides representatives of the protected health information of my child, as necessary: (i) to provide relevant information to SADD, Inc. or WorldStrides related to my child’s ability to participate in activities; and (ii) to provide relevant information to SADD, Inc. or WorldStrides to keep me informed of my child’s health status. I give permission to SADD, Inc. to allow photographs, video and audio recordings, and interviews to be taken of my child, and I authorize any such photographs, video and audio recordings, and interviews to be published along with the subject’s name and agree that they may be used to illustrate, report, promote, and advertise SADD, Inc. or partner organizations, including publication in print media, television, radio, or Internet websites. I understand that SADD, Inc. and WorldStrides reserve the right at any time to terminate participation in the SADD National Conference for any participant when, in the judgment of SADD, Inc. or WorldStrides staff, it is in the best interest of the program or participant to do so. I understand no full or partial refunds of conference fees will be given in this circumstance, and I agree to pay any additional fees required to arrange immediate transportation home for my child. I understand the signature of one parent or guardian on this release implies the consent of the other.

Parent/Guardian Signature: _____________________________________               Date: _________________________

Please complete this form and return it to your group leader as soon as possible.
He or she will then return it to WorldStrides.