WAIVER

Name of Event:
______________________________________________________________________________
Date: _________________________
Name: _______________________________________________________________________
Region & Local Chapter: ______________________________________________________

EMERGENCY INFORMATION:
Contact Person 1:_____________________ Contact Number: ____________________
Contact Person 2:_____________________ Contact Number: ____________________

MEDICAL INFORMATION:
List all the ailments your child suffer from:

______________________________________________________________________________
List any medication your child might need:

______________________________________________________________________________
Indicate any allergies with certain medications:

______________________________________________________________________________

I take responsibility for my child’s whereabouts after this activity.

I agree to waive, release, indemnify and hold harmless the National

Federation of Junior Philippine Institute of Accountants - Region IV, its officers,
members and all the organizers of this event from any claims of liability arising out
of my child’s participation in this activity. I also agree to waive that NFJPIA-
Region IV, its officers, advisers, members and all organizers of this event have
responsibility to my child only within the premises of the venue.

Should my child require medical attention as a result of accident or any serious

illness, I do hereby grant and bestow upon the organizers of this event permission
and authority for and on my behalf to authorize any licensed medical
practitioner to render medical aid and treatment.

CONFORME: __________________________________ ______________________

Signature above Printed Name Date