Plaza Bowl Prescott Printable Parent Permission Form . . .
PARENT PERMISSION SLIP MEDICAL TREATMENT AUTHORIZATION
ALL- NIGHT LOCK-IN Plaza Bowl 127 Plaza Drive Prescott, AZ 86303 phone (928) 445-8300fax (928) 541-0292
Fill in the form below and bring it with you.
I hereby give permission for my child __________________________________ , to participate in the Plaza Bowl All-Night Lock-In. (Please complete a separate form for each child.) In the event of injury, illness or emergency, I hereby authorize Plaza Bowl, and/or its agents and employees to secure medical care and treatment for my child, including, but not limited to x-ray, examination, anesthetic, medical, dental, or surgical diagnosis or treatment and/or hospital care as deemed reasonable necessary for the safety and welfare of my child. I agree to assume financial responsibility for any resulting medical charges. Please circle A or B below: A My child has no special problems or medical needs of which the staff should be aware. B My child is in need of special care: Medication:
Other:
Food or drink my child should not receive:
My child is allergic to:
I fully understand that my child is required to follow all rules and requirements governing conduct during the lock- in. I hereby acknowledge that if my child is determined to be in violation of these behavior standards, he/she will be sent home. I, the undersigned, hereby agree to release, hold harmless, indemnify, and waive all claims against Plaza Bowl, its related companies, and/or its agents and employees for any claims, law suits, and/or demands, in any way, relating to or arising from my childs presence on the premises.
Date: ____________ Parent or legal guardian: _________________________________