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Parent/Guardian

Health/Medical Information

I understand I shall be notified if a health problem or a medical crisis occurs which may require immediate medical care. However, if I cannot be reached by telephone, I authorize a representative from the City of Jackson to obtain medical attention to be performed as deemed necessary by licensed medical personnel, emergency ambulance personnel, hospital doctors and nurses. The City of Jackson, Department of Parks and Recreation, Jackson Zoo will not be liable for any medical bills should this become necessary.

Emergency Contact

Please list an Emergency Contact in the event of an emergency.

Pick-up Authorization

Field Trip Authorization

The child named on this application has my permission to attend the scheduled field trips which are organized by the City of Jackson Department of Parks/Jackson Zoo.  I understand I will be notified in advance of all field trips and of any additional fees or arrangements which may arise as a result of field trips.  Additionally, I understand transportation to and from the destinations will be by bus or van, and if I do not want my child to participate in any of the scheduled field trips, I will notify my child’s Center Coordinator in writing at least 24 hours before the scheduled field trip.

Photos/Videos Authorization

I agree that photographs, video tapes, motion pictures, recordings, or any other reproductions of my image may be used for the purpose of promoting programs operated or sponsored by the City of Jackson, Department of Parks and Recreation, Jackson Zoological Park. I hereby grant City of Jackson, Department of Parks and Recreation, Jackson Zoological Park permission to use such images in any media now or hereafter for any legitimate purpose whatsoever, and to use my name in connection therewith if the City of Jackson, Department of Parks and Recreation, Jackson Zoological Park so chooses.

I do give permission for to be photographed.

In consideration of benefits to be derived therefrom, I release the City of Jackson, Mississippi, or any of its employees, agents or servants of and from any and all claims, demands, damages, actions or causes of actions, either at law or equity of every nature and kind whatsoever because of any matter of thing done, omitted, or suffered to be done, by the said City of Jackson, Mississippi, or any of its employees, agents or servants.

I, the undersigned, verify the above information as being true and correct.  I understand that any misrepresentation above can result in disqualification from further participation.