Board Member Authorization Form

Member Name

Key Club Member Name (First, Middle, Last)(Required)

Mailing Address (Street, City, State Zip Code)(Required)

Gender(Required)

Birthdate (month/day/year)(Required)

Emergency Information

1) In case of emergency, please contact (first and last name)(Required)

Relationship to Key Club member(Required)

Cell Phone(Required)

Alternate Phone

2) In case of emergency, alternate contact (first and last name)(Required)

Relationship to Key Club member(Required)

Cell Phone(Required)

Alternate Phone

Medical Information

Health Insurance Company Name(Required)

Policy Number(Required)

Group Name or Number on Insurance Card(Required)

Telephone number or other contact information shown on insurance card(Required)

Does your Key Club member take any prescription medication or over-the-counter drugs of any type?(Required)

If yes, please explain.(Required)

List any allergies, medical conditions, or mental health concerns of which we need to be aware. Please explain any yes responses above. Please also list any dietary restrictions or dietary needs that would be important to know in general and for planning meals for the District Board.(Required)

Section Break

I am the parent or legal guardian for the above-named Key Club member, and give my permission for them to attend any convention, conference, board meeting, and/or other event(s) sponsored by Capital District Key Club. I understand that the parent or legal guardian signature on this form designates Capital Key Club District Administrator Ms. Kristina Dlugozima (or a designee – a member of the Capital District Key Club Adult Committee) to be the above-named Key Club member's chaperone. In the case of medical emergency, I understand that every effort will be made to contact the emergency contacts listed above. In the event those persons cannot be reached or time does not permit, I hereby give permission to a licensed physician or other licensed medical provider, to provide proper treatment, including but not limited to hospitalization, injection, anesthesia and/or surgery, for the above-named Key Club member. On behalf of myself and my ward/minor, I/we hereby RELEASE, WAIVE AND FOREVER DISCHARGE Capital District Key Club and its officers, directors, volunteers, employees, parents and subsidiaries, agents, from any and all claims, liabilities, causes of actions, damages, demands, judgments, executions, liens and costs whatsoever, in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (i) claims made against medical providers of emergency services under this authorization, or (ii) against Capital District Key Club for obtaining medical emergency services for said Key Club member pursuant to this authorization. (Required)

Signature(Required)

Date

Email Address of Parent/Legal Guardian Completing This Form

Cell Phone Number of Parent/Legal Guardian Completing This Form

Kids Need Kiwanis

Member Name

Emergency Information

Medical Information

Section Break

Upcoming events