The Brash Foundation

7-Week Summer Workshop

Summer 2019

Her Information

Her Name*

First NameLast Name

Birth Date*

MonthDayYear

Age*

Grade*

ElementaryMiddleHigh

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Contact Information

Name*

First NameLast Name

Cell Number*

Area CodePhone Number

Work Number

Area CodePhone Number

E-mail*

Is the home address the same as hers?*

YesNo

If No, please list address below:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number*

Area CodePhone Number

Does she have any allergies, food aversions, chronic illness, or medical conditions? If yes, please describe.*

Should paramedics be called?*

YesNo

Is she prescribed any medications that need to be taken regularly? If yes, please explain any instructions.*

Should paramedics be called?*

YesNo

Medical Information

Insurance

Policy Number*

Name of Health Insurance Provider*

Primary Care Physician Name & Address*

Physician Number*

Area CodePhone Number

Preferred Hospital*

Our first priority is ensuring that each girl is taken care of medically, safely, and carefully. Please ensure that you provide us with as much information as possible to ensure that her needs are met.

Thank you.

Release Statements

Informed Consent and Acknowledgement

I hereby give my approval for my daughter's participation in any and all activities prepared by The Brash Foundation during the selected retreat. In exchange for the acceptance of said daughter's candidacy by The Brash Foundation, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless The Brash Foundation and all its respective officers, agents, and representatives from any and all liability for injuries to said daughter arising out of traveling to, participating in, or returning from selected workshop sessions.

In case of injury to said daughter, I hereby waive all claims against The Brash Foundation, including all chaperones and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the workshop.

Medical Release and Authorization

As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to The Brash Foundation and its affiliates including Directors, Chaperones, and Team Leaders to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Photo Release

I hereby give permission for my daughter to be photographed during The Brash Foundation 7-Week Summer Workshop. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our sponsors and for promotional purposes including flyers, brochures, newspaper, The Brash Foundation website and social media. I understand that although my daughter’s photograph may be used for advertising, her identity will not be disclosed, I do not expect compensation and that all photos are the property of The Brash Foundation and its affiliates.

Transporation Release

I hereby give permission for the transportation of my child for official The Brash Foundation 7-Week Summer Workshop activities by modes of transportation agreed to by the organization's director if required.

Acknowledgements

The Brash Foundation and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Girls’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my daughter to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Parent / Guardian Signature*

Parent / Guardian Name*

First NameLast Name

The Brash Foundation Application

Her Information

Contact Information

Emergency Information

Medical Information

Release Statements