Forms: Liability and Medical Agreement

Parents, please fill out the permission slip and return to your child’s youth program staff and/or chaperone. This is only a permission slip for Uniting Three Fires Against Violence. If your tribal youth program requires their own permission slip in order to travel, attend events, tend to any emergencies, etc. with your child, please coordinate that information with your tribal youth program. At the time of your child’s registration, please attach this form with it.

You can mail, email or fax the Registration and Liability/Medical Agreement to:

Uniting Three Fires Against Violence
519 Court St. Suite A.
Sault Ste Marie, MI 49783
Fax: (906) 253-9757
Email: vpatzwald@utfav.org

Or hand this into your tribal youth program worker and they will ensure UTFAV receives this. If you have any questions or concerns, please feel free to reach out to Uniting Three Fires Against Violence at (906) 253-9775.

I/We, parent of the child named above, give full permission for my child to attend the UTFAV Tribal Youth Wellness Summit on July 16 - 18, 2018 being held at Camp Westminster on Higgins Lake, 116 Westminster Dr., Roscommon, MI 48653. By signing this permission slip, I accept general liability for the participation of my child in the activities listed above. I agree that Uniting Three Fires Against Violence, their staff, governing board, consultants and other participating agents, either jointly or separately, are free from and against any and all claims, injuries, damages, losses, costs, or other causes of action that may arise with this activity.

If my child were to have a medical emergency, I/We give UTFAV staff and their consultants, and the chaperones permission to seek medical attention for my child. By signing this I recognize that any cost to incur for administering medical attention is at the liability and responsibility of me acting as their parent and/or legal guardian. I will not hold Uniting Three Fires Against Violence responsible for any legal and/or financial costs or any other form of liability to seek emergency medical attention for my child. In the event of an emergency, please contact me at the number listed below.
Please list any medical condition that your child has that may impact their ability to fully participate: Example: Severe physical conditions, medicine, food allergies, etc