Kentucky DeMolay
               

               

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KENTUCKY DEMOLAY ACTIVITY PARTICIPATION FORM

Text Box: PARTICIPANT’S INDEMNIFICATION                                                                                                                                                                                                                                                                                         REQUIRED FOR ALL PARTICIPANTS   I hereby promise to conduct myself in a responsible manner and abide by the DeMolay rules and regulations, remembering that the future welfare of the Order of DeMolay is in my hands; and to follow all of the rules and regulations for this DeMolay event. If I do not abide by this promise, I will be subject to being returned home immediately at my own expense or, if an adult, asked to leave. In consideration of the DeMolay Staff accepting this registration, I shall indemnify and hold Kentucky DeMolay, DeMolay International, all Affiliated Organizations and the DeMolay Staff harmless from and against any and all penalties, losses, costs, damages, suits, judgements, claims, demands, expenses and liabilities of any kind or nature whatsoever, arising directly or indirectly out of or in connection with my attendance at this DeMolay event.   PARTICIPANT’S SIGNATURE _________________________________________________ DATE: _____________________

 

 

 

 

 

 

 

 

 

 

Text Box: HEALTH HISTORY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            REQUIRED FOR ALL PARTICIPANTS   The DeMolay Staff should be aware that this participant has experienced health problems with the following (Use back of form for further explanation, if necessary):   __ Participant has no health problems                                                           __ Appendicitis                                   __ Asthma                                                                                            __ Convulsions                                                    __ Cramps in Water   __ Diabetes                                           __ Ear Trouble                                                                      __ Epileptic Seizures                                                           __ Fainting                                                                                            __ Frequent Colds                               __ Heart Trouble                                                  __ Hernia                                                               __ Motion Sickness                            __ Respiratory Trouble                                       __ Rheumatic Fever  __ Sinus Trouble                                                __ Throat Infection                                                                                                                                                                                                                             __ Allergies, Medications, Other (Use back, if necessary): _______________________________________________________   ______________________________________________________________________________________________________                                   _ PARENTAL PERMISSION & MEDICAL RELEASE     REQUIRED FOR ALL PARTICIPANTS UNDER THE AGE OF 18   As the Parent or Legal Guardian of the participant named above, I hereby give my permission for the DeMolay Staff to enter the above named participant into a hospital of their choosing. They may also obtain medical attention or treatment by a physician, if in their opinion, the above named participant needs medical attention or treatment. This designation is made in accordance with the provisions of 45CFR 164.502(g)(1), and as such authorizes the attending physician to provide DeMolay Staff with all rights that I possess in and to the named participant’s medical and other protected health information under the Health Insurance Portability and Accountability Act of 1966 (“HIPAA”). I also realize that DeMolay members attending this event may be engaged in indoor and outdoor activities and other physical activities related to this event. To the best of my knowledge, there is no reason why the above named participant should not be allowed to participate in the activities of this DeMolay event. I also agree, upon notification from the DeMolay Staff, to pick up the above named participant, if, in the opinion of the DeMolay Staff, it is necessary that he/she be removed from the site of this DeMolay event. In addition, I agree on behalf of the above named participant, that his/her room may be entered for inspection by no fewer than two DeMolay advisors, if it is deemed necessary by the DeMolay Staff. In consideration of the DeMolay Staff accepting this registration, I shall indemnify and hold Kentucky DeMolay, DeMolay International, all Affiliated Organizations and the DeMolay Staff harmless from and against any and all penalties, losses, costs, damages, suits, judgements, claims, demands, expenses and liabilities of any kind or nature whatsoever, arising directly or indirectly out of or in connection with the above named participant’s attendance at this DeMolay event.   PARENT/ LEGAL GUARDIAN’S SIGNATURE: ________________________________________ DTE: _______________ _____________________________________________________________________________________________________     Name of Medical                                                                                                                                                                                                                                                                                                                                                                                                                  Name of Family Physician: ________________________________ Insurance Company _______________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Address: ______________________________________________ M                                                     REVIEWED & ACCEPTED--ADVISOR’S SIGNATURE: _______________________________________ DATE: _____________                                                                                                                                                                         Phone: (_____) ______________________________ In case of an emergency, contact:   Name: __________________________________________                  Contact’s Phone Information:   Address: ________________________________________                 Daytime Phone: (_____) ______________________   City ____________________________________________                 Nighttime Phone: (_____) _____________________   State: ____________________________ Zip: ___________                 Cell Phone: (_____) __________________________      

 

 

 

 

 

 

 

 

PARENTAL PERMISSION & MEDICAL RELEASE     REQUIRED FOR ALL PARTICIPANTS UNDER THE AGE OF 18

 

As the Parent or Legal Guardian of the participant named above, I hereby give my permission for the DeMolay Staff to enter the above named participant into a hospital of their choosing. They may also obtain medical attention or treatment by a physician, if in their opinion, the above named participant needs medical attention or treatment. This designation is made in accordance with the provisions of 45CFR 164.502(g)(1), and as such authorizes the attending physician to provide DeMolay Staff with all rights that I possess in and to the named participant’s medical and other protected health information under the Health Insurance Portability and Accountability Act of 1966 (“HIPAA”).

I also realize that DeMolay members attending this event may be engaged in indoor and outdoor activities and other physical activities related to this event.

To the best of my knowledge, there is no reason why the above named participant should not be allowed to participate in the activities of this DeMolay event.

I also agree, upon notification from the DeMolay Staff, to pick up the above named participant, if, in the opinion of the DeMolay Staff, it is necessary that he/she be removed from the site of this DeMolay event. In addition, I agree on behalf of the above named participant, that his/her room may be entered for inspection by no fewer than two DeMolay advisors, if it is deemed necessary by the DeMolay Staff.

In consideration of the DeMolay Staff accepting this registration, I shall indemnify and hold Kentucky DeMolay, DeMolay International, all Affiliated Organizations and the DeMolay Staff harmless from and against any and all penalties, losses, costs, damages, suits, judgements, claims, demands, expenses and liabilities of any kind or nature whatsoever, arising directly or indirectly out of or in connection with the above named participant’s attendance at this DeMolay event.

 

PARENT/ LEGAL GUARDIAN’S SIGNATURE: ________________________________________ DATE: ________________

 

 

REVIEWED & ACCEPTED--ADVISOR’S SIGNATURE: _______________________________________ DATE: _____________

 

 
               

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 KENTUCKY DEMOLAY ACTIVITY PARTICIPATION FORM

 
               
               
               
               
               
               
               
               
               
               
               

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