免责任及医疗授权书.doc

免責任及醫療授權書 本人子弟 經本人許可，請准予參加201樂健康營活動。 活動日期 : /29/12 (星期) 至/01/12 (星期) 活動地點 : 150 Commerce Road, Cedar Grove, NJ 07009 本人在此同意免除佛教慈濟基金會新澤西分會，及有關工作人員，任何在上述活動中可能發生之意外責任。本人佛教慈濟基金會新澤西分會沒有為學提供醫療保險任何意外責任。發生意外時，本人授權關工作人員代尋求，並 通知本人。 家長簽名 日期 __________  Liability and Waiver and Medical Consent Form My child, (name)________________________, has my permission to participate in the following Tzu Chi Mid-Atlantic Region 2012 Summer Camp: Dates: 06/29/2012 (Monday) – 07/01/2012 (Saturday) Location: 150 Commerce Road, Cedar Grove, NJ 07009 I hereby release the Buddhist Tzu Chi Foundation, Mid-Atlantic Regional Office and its associates (staff members, teachers, and volunteers) from any liability arising from the participation of the above activity. I understand that the Buddhist Tzu Chi Foundation, Mid-Atlantic Regional Office is not obligated to provide medical insurance for the participants and liability of accident, if it is incurred. In case of an emergency where medical assistance is required, camp staff will notify the undersigned at the following phone number (_______)_______-_________when seeking aid. Parent/Guardian Signature: __________________________ Date: ______________ 佛教慈濟基金會新澤西分會 Buddhist Tzu Chi Foundation, Mid-Atlantic Region 150 Commerce Road, Cedar Grove, NJ 07009 ? phone 973-857-8666 ? fax 973-857-9555  EMBED Word.Picture.8