NLC Emergency Form 2024

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This form must be completed for each person traveling to NLC with Texas FCCLA. Parents will need to assist students with completion of this form. Forms must be completed by April 30, 2024.

First and Last Name of Participant: *

Type of Participant: *

Student

Parent/Family Member

FCCLA Chapter Advisor

Other Guest

FCCLA Chapter/School Name: *

Participant Date of Birth: *

YYYY

Participant Home Address (include city, state, zip): *

Participant Cell Phone Number: *

In case of accident, illness, or emergency, please provide the name of an emergency contact for the participant: *

Emergency Contact Relation to Participant: *

Parent

Spouse

Sibling

Child

Other

Emergency Contact Cell Phone Number: *

List any additional emergency contacts and cell phone numbers here: *

List any known health conditions. If none, please type N/A. *

I authorize the Texas Association, Family, Career and Community Leaders of America through its agents, employees, or chaperones, and the advisor representing the school district to secure any medical or other emergency services which in their reasonable discretion they believe to be necessary or desirable for me/my child during the said trip, and to arrange for and provide transportation for me/my child from the meeting to destinations during the course of that time span. Said transportation may involve public transportation, transportation in a school vehicle or a private vehicle, or a combination thereof. *

I agree

I do hereby release and discharge and agree to indemnify and save harmless the Texas Association, Family, Career and Community Leaders of America, persons serving as employees, agents and chaperones of the Texas Association, Family, Career and Community Leaders of America, and the representatives from the school district from all claims, causes of action, damages, and liabilities whatsoever which might or could be asserted by me/my child, or against me/my child by others by reasons of the exercise of the authority in this document or of any transaction, occurrence, or event arising out of or related in any way to the trip to and from the specified meeting, and the stay in the meeting city. *

I agree

Please type your name/your parent's name here to indicate your acceptance of this document, acting as your signature. *

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