Idaho Association by tfGBNfa

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									                                     2012 State Leadership Conference
                           Attendee Release                                                                     Form 2
                                                                     Required for all Advisers, Members and Chaperones
                          Chapter Advisers: These forms will be your responsibility to obtain and have with you at State
                          Leadership Conference for each member attending, including yourself and any chaperones.
ATTENDEE: Name (print)                                                            Birth Date

* FILL OUT IF MINOR *
I give the above permission to attend the state-approved FCCLA State Leadership Conference at The Riverside Hotel in
Boise, Idaho April 12-14, 2012.
Parent/Guardian Signature                                                                  Date
Parent/Guardian Name
* EVERYONE FILL OUT *
Phone: Home                                Work                                    Cell
Home Address                                                                City,ST,Zip
Alternate Emergency Contact                                                Relationship
  Phone:                                   Work                                   Cell
  Hm Address                                                                City,ST,Zip
PERMISSIONS:
   Yes     No Permission for attendee to be photographed and/or videotaped during the Conference and allow use of
              said photo/video on the Idaho Division of Professional-Technical Education website.
   Yes     No Permission to the undersigned FCCLA Adviser to seek and/or approve emergency medical attention for
              my child, should it become necessary and I cannot be immediately contacted after reasonable effort.
   Yes     No Permission for attendee to participate in the Idaho FCCLA Stomp Out Hunger service learning project
              Friday, April 13, 2012.
   Yes     No Permission for attendee to participate in the Fun Run on Saturday morning.
INSURANCE:          Yes       No I have obtained insurance for/as the attendee while attending this meeting or have a
                                 family policy which will cover this activity.
                           Policy: Name and ID Number
                                  Subscriber Name
I understand the school district and state association are not responsible for providing insurance and that a student will
not be allowed to travel without some form of personal health insurance.          (Attendee/Guardian initials)
HEALTH:
Activities the attendee is restricted from for medical reasons:
List any medical/physical condition(s)
List any medication(s) being taken by attendee (include dosage):



Adviser Signature                                                          Chapter

  * * * * * * * * NO STUDENT WILL BE ALLOWED TO TRAVEL WITH AN FCCLA GROUP WITHOUT ABOVE INFORMATION * * * * * * * *

								
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