Parental Consent/Medical Waiver Form

Please print this form and mail it to the Registrar as soon as you fill out your application.

******YOUR APPLICATION WILL NOT BE ACCEPTED UNTIL THIS SIGNED FORM IS RECEIVED!!******

My/Our child, _______________________, has my/our permission to attend the chrysalis weekend. In the event of an emergency and I can not be reached by phone, the Chrysalis staff has permission to secure the services of  licensed medical professionals to provide the care necessary, including anesthesia, for my child's well-being.

Insurance Company: _________________________________ Policy No: ________________

Parent's/Guardian Signature: __________________________  Phone: __________________

Other Emergency Contact: ____________________________ Phone:  __________________

Other Emergency Contact: ____________________________ Phone:  __________________

Mail To:

Cristol Cannon

105 Ovid Drive

Dublin, GA  31021

478.272.1917