Parent's Approval and Student Waiver - Bells Mill Bash June 9, 2023
This form is required by the BMES Parent Teacher Association insurance policy. Please complete this form for all minors prior to attending the event.

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The following minor(s) has/have my (our) permission to participate in the Bells Mill Bash June 9, 2023 at Bells Mill Elementary School. *
I (we), as parent(s) or guardian(s) of the minor(s), do hereby, for my (our) self, my (our) student heirs, executors and administrators, remise, release and forever discharge Bells Mill Parent Teacher Association and the Free State Parent Teacher Association, and all officers, employees and agents of each of the foregoing, acting officially otherwise, from any and all claims, demands, actions or causes of action on account of referred.
And I hereby certify the minor(s) is/are my (our) student(s): *
Required
His/her/their date(s) of birth is/are: *
And I (we) do hereby certify that to the best of my (our) knowledge and belief said minor(s) is/are in good health. In case of illness or accident, permission is granted for emergency treatment to be administered. It is further understood that the undersigned will assume full responsibility for any such action, including payment of costs.
I (we) hereby advise that the above named minor(s) has/have had the following allergies, medicine reactions or unusual physical condition which should be made known to a treating physician. (If none, please write the word “none’.) *
SIGNATURE
This form must be signed electronically by at least one parent or guardian of the minor(s).
Parent/Guardian Name (Signature) *
Parent/Guardian Address *
Parent/Guardian Phone Number *
A copy of your responses will be emailed to the address you provided.
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