Chapter Name___________________________________                   Date_____________

I, the undersigned Parent or Guardian of __________________________, do hereby give 
my consent and permission for him/her to participate in Chapter, Jurisdictional or 
Regional DeMolay Activities. I understand all activities and events of any duly 
chartered Chapter, Order of DeMolay, of the Jurisdiction of Alabama, including any 
activities conducted at the state or jurisdicitonal level, or by the International 
Supreme Council, Order of DeMolay; WITH THE FOLLOWING EXCEPTIONS: (State on lines 
below, if NONE, write (NONE) 
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In the event of injury or illness to the above named minor, I, the undersigned 
Parent or Guardian, hereby authorize any adult DeMolay Advisor in attendance to 
secure, and any physician in attendance to provide, such emergency medical treatment 
as shall be deemed necessary by those present, including but not limited to 
hospitalization, injections, anesthesia, surgery, x-ray, blood and medications.  I 
understand that every reasonable effort shall be made to contact me prior to medical 
treatment. 

The above named minor is subject to the following medical problems, and/or is 
receiving treatment under the suprevision of proper medical authorities as follows:  
(State on lines below, if NONE state NONE)________________________________________
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Neither DeMolay International nor the jurisdiction of Alabama, Order of DeMolay, 
maintains any medical insurance for its members.  I understand that we will be 
responsible for any and all costs of medical treatment incurred by or on behalf of 
the above named minor. My family health insurance carrier and policy numbers are as 
follows: 

Insurance Company Name:___________________________ Policy Number(s)_______________

Policy Holder's Name:_____________________________________________________________