Student's Name:
Home Address:
Name of School/Agency/Group:
Allergies or Medical Concerns to be aware of:
The above named student may participate in the Day Visit Program offered at Old McDonald's Farm, Inc. (OMF). I have the authority to act on this student's behalf and I release OMF and its representatives from liability in the event of accidental injury or illness. I give my permission for this student to receive emergency medical treatment. I accept full responsibility for any expense incurred in providing medical treatment for this child.
I hereby grant OMF the right to use forever any film, video tape, audio tape, photographs, slides, or combination thereof, for inclusion in any promotional or advertising purposes and my child agrees to appear without pay. I also give my permission for my child to be interviewed, quoted and have name printed in the media for the promotional purposes of OMF. (Please cross just this section off and write "no" and initial if you do not want pictures or interviews taken of this student.)
Parent/Guardian Printed Name:
Parent/Guardian Signature:
Today's Date:
Parent/Guardian Day Time Phone: