Felicia Ray & Company

 

Medical Release & Food Allergy Agreement
(You must sign a separate agreement for each child you are signing for.)

In case of a medical emergency, I grant consent to Lli Sewing School to authorize medical care for my minor child:  age .

Our family doctor is:

 

Our family doctor's address is:

 

The hospital we use is:

 

Contact me immediately at:

 

If I cannot be contacted and a reasonable effort has been made to do so, I authorize Lil Sewing School staff and his or her designee to act on my behalf. I further authorize my son/daughter to be transferred and admitted to any hospital or medical facility for diagnosis and treatment if deemed necessary. I request and authorize any duly licensed Doctors of Medicine, Doctors of Dentistry or other such licensed technicians or nurses to perform any diagnostic, treatment or operative procedures including x-ray diagnosis of my child. I assume the responsibility for the payment of any such transfer and treatment.

Alternative contact name and number:

 

 

 

If your child does not have allergies, please check this box and sign the document below

 

If your child has allergies, please complete the following information before signing this document:

Since my child has allergies I understand that I need to present the following to Lil Sewing School:


1. A detailed description of the allergens to which my child is allergic and symptoms of a reaction. (Food Allergy Action Plan Form or other documentation if this form is not applicable).


2. A letter signed by me and my child’s doctor with instruction to follow in the event my child experiences an allergic reaction. (Waiver for the Distribution/Administration of Medication Form).


3. An epinephrine kit with 2 epipens, if prescribed, or other medication to be used if an allergic reaction occurs.

  • I understand that all medications must be in the original container, and must be clearly labeled with my child’s name.
  • I understand that my child’s medical needs will be posted in the classroom, so that all staff will be aware of those needs.
  • I understand and agree to the above and agree that Lil Sewing School and it’s staff will not be held liable in so far as they administer medical care in conformance with the information provided on my child’s medication consent form and food allergy action plan. I understand that the Lil Sewing School will use reasonable care in doing so.

LIABILITY RELEASE:

I certify that the information described above is accurate and complete to the best of my knowledge. I understand that each individual is responsible for his/her own insurance coverage for medical treatment. I hereby release Lil Sewing School, Felicia Ray & Company, their Staff, and any designated individual in charge of the Lil Sewing School activity from any legal or financial responsibility with respect to my personal or my student/child's participation in or contact with any known element associated with my participation in activities and programs at Lil Sewing School.

I certify that I am the parent/legal guardian of the above-named student; that I have read and understand this agreement. I certify that I have explained the risks and dangers to my child. I hereby release and hold harmless Lil Sewing School, its partners in education, coaches, volunteers, medical personnel, security officers, administrative officials, other employees, volunteers and agents from any liability, actions, causes of action, claims, judgments cost or expense, including attorney fees, known or unknown at this time, arising out of or in any way related to any injury or illness incurred by myself or my child while participating in, any activity or program. I have voluntarily chosen to allow my child to participate and assume all such dangers and risks. I request that my son/daughter be permitted to participate in activities and programs sponsored by the Lil Sewing School.

NOTICE: You must sign a separate agreement for each child you are signing for.

Please enter the minor student's full legal name below

Please enter the full legal name of the adult student signing this form and/or parent or legal guardian of the minor student.

Leave this empty:

Signature arrow sign here

Signed by Felicia Ray
Signed On: February 1, 2022


Signature Certificate
Document name: Medical Release & Food Allergy Agreement
lock iconUnique Document ID: b571a249d5b70682e09909cad8f2b637736549d1
Timestamp Audit
January 29, 2022 3:18 pm CDTMedical Release & Food Allergy Agreement Uploaded by Felicia Ray - support@feliciarayco.com IP 162.235.61.15