INTERNATIONAL ORDER OF THE RAINBOW FOR
GIRLS
PARENTAL RELEASE FORM
CHILD’S NAME
____________________________________________
DATE:__________________________
I
do hereby grant my permission for hospital or medical personnel to administer
immediate treatment to my child should she be injured or become ill while
traveling to and from or during a Rainbow activity. I also agree to hold harmless the
International Order of the Rainbow for Girls and its workers for any injury
incurred as a result of my daughter’s participation.
PARENT NAME (PRINT)____________________________________
SIGNATURE______________________________________________
ADDRESS___________________________________________________
Street City Zip
HOME PHONE (_____)____________BUSINESS PHONE(_____)___________
INSURANCE
COMPANY____________________________________________
POLICY
#________________________ ID
#____________________________
ALLERGIES:
_________________________________________
LIST
ALL MEDICATIONS CURRENTLY TAKING:______________________
__________________________________________________________________
__________________________________________________________________
FAMILY PHYSCIAN
_____________________ PHONE # (____) ____________
OTHER INFORMATION
_____________________________________________
__________________________________________________________________
Each year the Mother
Advisor is to keep the original and a copy will be provided to the Supreme
Deputy of