MARCH ON WASHINGTON

October 2, 2010
Washington, District of Columbia

YOUTH PERMISSION FORM

This form is to be completed for each individual youth attending the One Nation Working
Together March in Washington, District of Columbia.

NAME__________________________________________AGE______DOB_______________

ADDRESS____________________________________________________________________

CITY/STATE/ZIP_______________________________________________________________

TELEPHONE ( ) ______________________________________________________________

CONSENT:

I (We), the parent (s)/guardian (s) of the above-named child grant said minor permission to attend
the One Nation Working Together March to be held in Washington, District of Columbia. I
(We) further forever release, acquit, and discharge the One Nation Coalition, its agents, servants,
or employees from any and all liabilities, claims and causes of action, which I/We may have by
reason of said attendance.

While attending the march, my child will be under the direct supervision of
Mr./Ms./Mrs._____________________________________ of the __________________ Youth
Council and, therefore, has the authority to act as parent or guardian for the duration of my child’s
stay at the march.

Parent(s)/Guardian(s)
Signature___________________________________________Date_______________________

Parent(s)/Guardian(s)
Signature___________________________________________Date_______________________

__________________________________________________________
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 MARCH ON WASHINGTON
October 2, 2010
Washington, District of Columbia

AUTHORIZATION FOR EMERGENCY MEDICAL

TREATMENT

NOTE: Please prepare one form for each individual youth.

NAME_____________________________________AGE_____DOB_________SEX_________

ADDRESS ____________________________________________________________________

CITY/STATE/ZIP ______________________________________________________________

TELEPHONE ( ) ____________________________________________________________

In case of emergency, contact: _____________________________________________________

Telephone ( ) _______________________________________________________________

HOTEL ASSIGNED_____________________________________________________________

CONSENT:

I __________________________________________________, the parent (s)/guardian (s) of the

above-named child hereby give consent and approval for him/her to attend the One Nation
Working Together March in Washington, District of Columbia. We hereby authorize
________________________________________ to take emergency actions on behalf of my/our
child in the event of accident or illness during the course of the march.

Parent(s)/Guardian (s)
Signature____________________________________________________Date______________

Insurance Carrier________________________________________________________________

Identification Number ________________________________Group Number_______________

Personal Physician ______________________________________________________________

Telephone ( ) _______________________________________________________________

Please give us any additional information that would facilitate care in a health or medical
emergency (i.e., special medications, physical disabilities, allergies, heart condition, seizures,
etc.): _________________________________________________________________________
______________________________________________________________________________
__________________________________________________________
______________________________________________________________________________
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