PKC Child Medical/Allergy Waiver and Model Release

*Waivers are valid for one year unless changes need to be made.

CHILD'S NAME *
CHILD'S NAME
BIRTHDAY *
BIRTHDAY
Section 1- CHILD MEDICAL/ALLERGY WAIVER
PLEASE READ CAREFULLY!
THIS SECTION IS VERY IMPORTANT FOR THE SAFETY AND WELL-BEING OF THE CHILD LISTED ABOVE. IN ORDER TO PROPERLY FILL OUT THIS SECTION OF THE FORM, YOU MUST KNOW IF THE CHILD HAS ANY SERIOUS MEDICAL CONDITIONS, FOOD ALLERGIES, AND/OR OTHER ALLERGIES.
LIST ALL KNOWN ALLERGIES. IF CHILD HAS NO KNOW ALLERGIES, SIMPLY ENTER ''NKA OR N/A'' IN THE BOX BELOW.
DOES YOUR CHILD HAVE AN EPIPEN? *
LIST ANY KNOWN MEDICAL CONDITIONS THAT YOU BELIEVE OUR INSTRUCTORS/STAFF SHOULD BE AWARE OF WHILE YOUR CHILD IS UNDER OUR SUPERVISION. THIS IS NOT REQUIRED, BUT THIS TYPE OF INFORMATION CAN OFTEN BE HELPFUL TO OUR INSTRUCTORS/STAFF IN CASE THERE IS AN EMERGENCY.
Section 2- CHILD MODEL RELEASE
PLEASE READ CAREFULLY!
AT PALMETTO KIDS COOKING, LLC WE USE VARIOUS FORMS OF MEDIA (E.G. PHOTOGRAPHS/VIDEO & AUDIO RECORDING) TO CAPTURE KIDS ENJOYING OUR CLASSES. CAMPS, PARTIES, AND OTHER EVENTS. WE OFTEN SHARE THESE MEMORABLE MOMENTS ON OUR WEBSITE AND SOCIAL MEDIA PLATFORMS. WE MAKE EVERY EFFORT TO EDIT OUT ANY OF YOUR CHILD'S PERSONAL INFORMATION (E.G. NAME TAGS) AND/OR ANYTHING THAT MAY BE CONSIDERED INAPPROPRIATE OR PROVOCATIVE. THE SAFETY OF ALL CHILDREN IS OF UPMOST IMPORTANT TO US AT ALL TIMES.
CHILD MODEL RELEASE *
Section 3- EMERGENCY CONTACT INFORMATION
PRIMARY EMERGENCY CONTACT NAME: *
PRIMARY EMERGENCY CONTACT NAME:
PRIMARY EMERGENCY CONTACT PHONE *
PRIMARY EMERGENCY CONTACT PHONE
Section 4- LEGAL RESPONSIBILITY
TERMS OF AGREEMENT *
BY CHECKING THE BOX BELOW, I AM HEREBY STATING THAT THE INFORMATION PROVIDED ABOVE IS BOTH TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I AM AUTHORIZED TO FILL OUT THIS FORM AND PROVIDE THE CORRECT INFORMATION.
YOUR NAME *
YOUR NAME
TODAY'S DATE *
TODAY'S DATE

 

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