High Risk Activity Permission Form

Enrollment ID

Youth Contact ID

BIG Contact ID

Guardian Contact ID

Match ID

Your Information

Your First Name

Your Last Name

Child's First Name

Child's Last Name

Big's First Name

Big's Last Name

What high-risk activity will the Big/Little be participating in?

Provide any further detail needed that the Big/Little will be participating in.

I give permission for my child to participate in the described activity/activities. I DO NOT give permission for my child to participate in the described activity/activities.

With my electronic signature, I hereby waive and release Big Brothers Big Sisters of Greater Chattanooga and all individuals, staff members, or volunteers working in connection therewith from any and all possible claims for injury to person or property which might arise with my child’s participation in the above activity. I do not hold Big Brothers Big Sisters of Greater Chattanooga or Big Brothers Big Sisters of America, staff, or volunteers responsible for any accident or illness which might occur and authorize the adult in charge (should it be necessary) to secure the service of a doctor at my expense.

Emergency Contact Information

In the event of an emergency and I am unable to be contacted, the following are sources of assistance.

Doctor (Name and Number)

Insurance Policy Information

Allergies

Medications

Additional Emergency Contact Name

Emergency Contact Number

Contact Information