Youth Name (s) Parent Name (s) E-mail address Street Address CityStateZip Youth’s Social Security # (opt.)Phone Birth dateGrade
For student to fill out:
Yes No
For parents to fill out: Pick One
Please note: Payment options will be provided on the next page, after submitting this form.
In case of emergency please notify: Name Phone Relationship Alternate Phone Relationship Does the youth have medical insurance coverage? Yes / No Name of Primary Care Physician Name of ProviderPhone Plan Account # Does the youth have dental insurance coverage? Yes / No Name of Dentist Name of ProviderPhone Plan Account # TREATMENT: Does the young person have a medical condition that a doctor or medical professional should be informed of in case of an emergency? Please be specific.
Drug or food allergy? Chronic illness or condition, physiological or behavioral? Need to take regular medication? Other?
RELEASE:
Please mark each item according to how they aply to your child.
I am the legal guardian/parent of the youth listed above. He/she/they have my permission to participate in the activities of Dharma Rain Zen Center’s Dharma School. I have filled out this form fully and accurately to the best of my knowledge. I have read the above release, crossed out any and all passages that are not acceptable and agree to release Northwest Zen Sangha, Dharma Rain Zen Center, Great Vow Zen Monastery and the staff of the Dharma School and Mandala on the Mountain Dharma Camp from any liabilities that might accrue from reasonable and normal activities during the time my child in their care. I have had all questions that I may have answered to my satisfaction. I will stay aware of the curriculum of the Dharma School so that I may support my child’s growth in understanding. I believe he/she is prepared to participate fully and have a good time.
I agree in full with the preceeding statement: Yes / No
Full Name, Custodial parent or guardian : Date: