4/19 MOMC EVENT - DOBBINS AFB

Month of the Military Child Event (Dobbins AFB - Hangar 5) Saturday, April 19th

* Indicates required field

Soldier/DoD Employee Name *

First

Last

Phone Number *

Unit or DoD Civilian *

Email *

Number of Adults in Party *

Number of Children in Party *

Children's Ages *

Emergency Contact (non-attending contact) *

First

Last

Phone Number *

Base Access

Events at Dobbins ARB require a Military ID to access the facility.

Please Check an Option Below: *

Someone in my party has base access I will need base access

Medical Release

If you or your child have allergies, medication needs, or any other medical condition we need to be aware of, please complete the information in the box below.

Food Allergies *

Medical Needs (non-food allergies or disability accommodations) *

Emergency Consent to Treat

I authorize and consent to medical, surgical, hospital care, treatment and procedures to be deemed immediately necessary to advisable by a physician to safeguard my child's health during Georgia National Guard Youth Program events. I waive my rights of informed consent to such immediately necessary treatment. I also authorize a copy of this consent to be treated with the same authority as the original one.

Authorization to Treat *

Consent

Signature For Consent (Guardians for 17-under) *

Photo Release

This event is being recorded and/or photographed. By attending this event, you consent to your likeness, image, and/or voice being recorded and/or photographed and used by Georgia Tech & the Georgia National Guard Youth Program without compensation for any purpose within Georgia Tech or the Georgia National Guard Youth's mission. You release Georgia Tech and the Georgia National Guard Youth Program for any liability resulting from such usage. If you do not wish to be subject to the foregoing, do not attend this event."

Choose One *

I Consent to the Above Photo Release

Guardian Signature *

First

Last

Submit