Coastal Leadership Academy
Liability Release Form for Guest
This form is only for the attendees who are NOT already CLA Students
All forms must be filled out and signed BEFORE the CLA Event.
CLA Prom
April 11, 2015
Name of Attendee: __________________________________________________________________________________________
Guest Of: __________________________________________________________________________________________________
Attendee Address: ____________________________________________ City ___________________________ State ________
Phone: ____________________________________________________________________________________________________
Emergency Contact Information:
Name: ___________________________________________Relationship (ie: parent, neighbor, etc.) ________________________
Home Phone: ______________________________________ Cell Phone: ____________________________________________
Allergies/Medications/Unusual Physical Conditions (Choose One & Sign)
I hereby advise that the student listed above has the following allergies, medicine reactions, or unusual physical
conditions which should be made know to a treating physician.
Please List all Allergies or Medical Conditions: _____________________________________________________________________
__________________________________________________________________________________________________________
Parent Signature: __________________________________________________________________________________________
I hereby advise that the student listed above DOES NOT have allergies, medicine reactions, or unusual physical conditions
which should be made known to a treating physician.
Parent Signature: __________________________________________________________________________________________
Acknowledge and agree that you have read all information below by INITIALING each item that is true:
 I understand and acknowledge that events involved in the CLA High School Prom on April 11, 2015 pose risks, including the risk of
serious injury or death. ___________
 I hereby certify that to the best of my knowledge and belief, the student listed above is in good health. __________
 In the case of illness or accident, permission is granted for emergency treatment to be administered. It is further understood that
the undersigned will assume full responsibility for any such action, including payment of cost. __________
 I hereby certify that I have read and understand this document. __________
I do hereby, for myself, and my heirs, agree to remise, release, and forever discharge Coastal Leadership Academy and all
employees, board members, coordinators, and volunteers of this organization, from any and all claims, demands, actions or causes
of action which in any way arise from my student’s participation in the above noted event.
Parent Signature: __________________________________________________ Date: _________________________
Please contact Karla Brooks at kbrooks@coastalleadership.org if you have any questions.