Rainbow Girls Medical Consent and Photo Release
Step 1 of 2: Submit
Full Name
*
Full Address
*
Active Member Full Name
Relationship to Active Member
*
If Rainbow Girl in MA, please choose your Assembly:
Wollaston #10
Taunton #13
Brockton #20
Natick #28
Haverhill #39
Wakefield #43
Framingham #47
Concord #53
Middleboro #58
Newton #60
Billerica #61
Cape Cod #66
Spencer #72
West Springfield #79
Gardner #83
Plymouth #86
Wamesit #88
Oxford #89
Georgetown #98
Barre #114
DECLARATION
I hereby promise to conduct myself according to Rainbow rules and regulations while attending any and all Rainbow events. If I do not abide by this agreement, I will be sent home at my own expense. I hereby release and hold harmless, the International Order of the Rainbow for Girls and any adults working with Rainbow from all liability incurred at Rainbow events.
Health History
Please list any health/medical concerns:
Name of Medical Insurance Carrier
*
Policy Number
*
Family Physician Name
*
City & Phone of Physician
*
Please list all allergies
Please list medications, dosages and frequency currently taken
*
Emergency Contact
Full Name of Emergency Contact
*
Full Address
*
Telephone Number
*
Releases
PARENTAL RELEASE FORM REQUIRED FOR THOSE UNDER 21 YEARS OF AGE.
Whenever it is deemed necessary, I authorize the calling of a doctor and/or providing of other necessary medical services, and I agree to pay for the same through insurance or by other personal means. I understand that reasonable measures will be taken to safeguard the health and safety of my daughter and that I will be notified as soon as possible in case of an emergency. I agree to indemnify and hold harmless all group leaders or any other representative of the International Order of the Rainbow for Girls in the event of sickness or accident.
Agree
*
PHOTO RELEASE
Pictures taken at Rainbow events may be posted on the Massachusetts and Supreme Assembly Rainbow websites. (Only first names will appear on the websites or social media accounts). If you prefer your daughter's photograph
NOT
appear on the websites or in other publications, please indicate here and inform your Mother Advisor.
Please confirm
*
Agree
I do not wish to have my daughters photo posted to the websites or in future publications
*
indicates required fields