2018 Washington Youth Tour Electric Cooperatives of Arkansas Medical Information and Release Form Step 1 of 2 50% Your sponsoring electric cooperative, Arkansas Electric Cooperative Corporation (AECC), and the National Rural Electric Cooperative Association (NRECA) collect the information contained in this form to provide or arrange first aid and other medical treatments for participating students of the Electric Cooperative Youth Tour to Washington. We reserve the right to refuse participation to your child in the tour in the event you refuse to provide the requested information. The information collected will be kept by AECC and NRECA staff and made available to medical staff in the case of an accident or emergency. This information is not shared for any other purpose. Student Name: First Middle Last Age:Parent(s) Name:Home Phone #:Work Phone #:In case of emergency, contact:at:Name of Family Physician:Ph. #:Do you have medical insurance:YesNoName of medical insurance company:Policy No.:Phone number of medical insurance authorization:PLEASE LIST ALL PRESCRIPTION MEDICATIONS THAT YOU ARE CURRENTLY TAKING:PLEASE LIST ANY MEDICATION THAT YOU ARE OR MAY BE ALLERGIC TO: LIST ANY ILLNESSES THAT YOU HAVE AND ALL CONDITIONS AND/OR TREATMENT FOR WHICH YOU ARE CURRENTLY UNDER THE CARE OF A PHYSICIAN OR ARE UNDER MEDICAL SUPERVISION. PLEASE LIST ALL MEDICAL CONDITIONS OR PROBLEMS THAT MAY REQUIRE SPECIAL CARE OR ATTENTION: SOME MEDICAL CONDITIONS MAY REQUIRE A DOCTOR’S CERTIFICATE OR MEDICAL CLEARANCE PRIOR TO THE TOUR, WHICH STARTS June 8, 2018. THE UNDERSIGNED HEREBY RELEASES AND FOREVER DISCHARGES ARKANSAS ELECTRIC COOPERATIVE CORP., ITS BOARD, OFFICERS AND EMPLOYEES AND ELECTRIC COOPERATIVE'S NAME: ITS BOARD, OFFICERS AND EMPLOYEES FROM ANY AND ALL CLAIMS, CAUSES OF ACTION OR LIABILITY, WHETHER KNOWN OR UNKNOWN, RELATING TO ANY MEDICAL CONDITION EXISTING ON THE DATE HEREOF, WHICH CLAIMS, CAUSES OF ACTION OR LIABILITY ARISE OR RESULT FROM PARTICIPATION IN THE ELECTRIC COOPERATIVE YOUTH TOUR. I/WE ALSO AGREE TO INDEMNIFY AND HOLD HARMLESS THOSE PERSONS OF THE ABOVE STATED ORGANIZATIONS AND SAID ABOVE STATED ORGANIZATIONS ON ANY CLAIMS FOR DAMAGES, LIABILITY, INJURY, EXPENSE, OR LOSS ARISING OUT OF THE ELECTRIC COOPERATIVE YOUTH TOUR. I certify that I have answered the above questions as accurately as possible, and that all known medical information about this student has been listed accordingly and that I/we have read, understand and acknowledge that I/we are releasing Arkansas Electric Cooperative Corporation and ELECTRIC COOPERATIVE'S NAME: from any and all claims, causes of action and liability which, may arise as a result of said medical conditions which were listed or should have been listed above. In addition, in case of accident or need for medical attention I/we give permission to the Electric Cooperative Youth Tour staff to take participant Participant's Name: to a doctor and/or medical facility. (It being understood that all expenses for treatment provided will be borne by the parent, guardian, or participant.) Signature of Parent:Signature of Student: This iframe contains the logic required to handle Ajax powered Gravity Forms.