_____________________________________ has my permission to attend the North GA Chrysalis weekend #______. In the event an emergency arises and I cannot be reached by phone, the Chrysalis staff has my permission to secure the services of licensed medical professionals to provide necessary medical care, including anesthesia, for my child’s well-being. We further do hereby release and discharge Chrysalis, its Board and members from any and all liability from illness, injuries, and damages that may arise out of or resulting from my child’s participation in or traveling to or from this event. I grant permission to North GA Chrysalis to use photographs of my minor child in print, audio-visual or online materials designed for informational or educational purposes related to North GA Chrysalis without compensation or approval rights.

Parent/Guardian Signature______________________________

Date_____/_____/________ Phone_______________________