Gifted Youth Mensa

Minor Child(ren) Name(s) *

Activity/Event Name *

Parent/Guardian Phone Number *

Parent/Guardian Email Address *A copy of this form will be sent to this email address

Emergency Contact Information

If you cannot be reached, the following person is authorized to act on your behalf:

Emergency Contact Name *

Emergency Contact Address *

Relation to Participant *

Emergency Contact Phone *

Medical Information

Physician's Name

Physician's Phone

Allergies or Additional Remarks

Liability Release & Media Consent

I hereby release American Mensa Ltd. and all its members, staff and officers, as well as the member-host of this event ("Mensa") from any liability for any harm to my child/children suffered during or as a result of participation in this event, including but not limited to physical injuries or psychological injuries. I acknowledge that my child/children might be exposed to topics or language of an adult nature and release Mensa from any liability for any harm alleged to be caused by it. I will indemnify and hold harmless Mensa for any damage caused or liability incurred by my child/children.

Media Consent *

Do you give consent for photographs, video, or audio recordings in which your child/children appears to be used by Mensa, including on Mensa-owned websites?

I DO give my consentI DO NOT give my consent

Signature

Print Parent/Guardian's Name *

Parent/Guardian's Signature *

Sign above using your mouse or touch screen

Date

Permission Form for Minors

Emergency Contact Information

Medical Information

Liability Release & Media Consent

Signature