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Medical Authorization
Step
1
of
4
25%
Participant Information
Name
(Required)
First
Last
Birthdate
(Required)
Please list all allergies or pertinent medical conditions Back2Back Cincinnati should be aware of regarding the participant
(Required)
Emergency Contact Information
Guardian's First and Last Name
(Required)
First
Last
Guardian's Phone Number
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Emergency Contact's First and Last Name
(Required)
First
Last
Emergency Contact's Phone Number
(Required)
Custody
(Required)
Please list information regarding custody arrangements/restraining orders (persons who may not visit or take your child under any circumstances) or indicate if this does not apply. Please be aware Back2Back Cincinnati cannot withhold a child from a parent/guardian without appropriate court documents stating such on file
In Case Of Emergency:
(Required)
If the guardian and emergency contact listed above are not available in an emergency, I give permission for Back2Back Cincinnati staff to plan for the care of me/my student(s) and/or transport me/my student(s) to the hospital.
Yes
No
Guardian Signature (if participant is under 18)
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Participant’s Signature (if over 18)
First
Last
Date
MM slash DD slash YYYY
Sponsor A Child or Family
Release of Information
Name of Participant
(Required)
First
Last
Release of Information (ROI) Consent
I understand my student’s story and/or my story is ours to share. I understand Back2Back Cincinnati will hold our information confidential unless necessary by law. I realize Back2Back Cincinnati can better serve my student and/or our family when they communicate to other individuals working with my student and/or our family. I give permission for Back2Back Cincinnati to give and receive information in regards to my student(s) and/or myself from Hamilton County Juvenile Detention Center (20/20), Hamilton County Juvenile Probation, Hamilton County Public Defender’s Office, Hamilton County Diversion Court Programs, Hamilton Prosecutor’s Office, and Hamilton County Juvenile Court.
Consent
(Required)
I CONSENT to the release of information.
Name of Consenting Guardian or Student (if over 18)
(Required)
Submitting your name below as a digital signature, you are acknowledging any release of information and understand that the permission can be revoked at any time by contacting Back2Back Cincinnati in written format either in email or letter.
First
Last
Date
(Required)
Provide the date of consent and submission of this form.
MM slash DD slash YYYY
Take A Mission Trip
Student Name
(Required)
First
Last
Additional Student Name
First
Last
Parent/Guardian Name
(Required)
First
Last
Field Trip Consent
Please provide consent or deny consent for the following planned field trip. A Yes or No response is required for every field trip. "Yes" indicates consent while "no" will result in a denial of consent and your student will not be able to participate in the activity.
Newport Levee | Monday 6/10/24 | 2:30-4:30
(Required)
One Levee Wy, Newport, KY 41017 | Pick Up at 2:30 pm, Drop Off at 4:45 pm
Yes
No
Mt. Echo | Monday 6/17/24 | 2:30-4:30
(Required)
251 Mt Echo Park Dr, Cincinnati, OH 45205 | Pick Up at 2:30 pm, Drop Off at 4:45 pm
Yes
No
Dunham Pool | Monday 6/24/24 | 10-2
(Required)
4356 Dunham Ln, Cincinnati, OH 45238 | Pick UP: 9:45 Drop OFF: 2:15 | Swimsuit Required
Yes
No
Kings Island | Monday 7/1/24 | 10-3
(Required)
6300 Kings Island Dr, Mason, OH 45040 | Pick UP: 9:45 Drop OFF: 3:15
Yes
No
French Park | Monday 7/8/24 | 2:30-4:30
(Required)
3012 Section Rd, Cincinnati, OH 45237 | Pick UP: 2:15 Drop OFF: 4:45
Yes
No
FC Cincinnati Game | Saturday 7/13/24 | 7:30-9:30
(Required)
1501 Central Pkwy, Cincinnati, OH 45214 | Pick UP: 7 Drop OFF: 10
Yes
No
Washington Park | Monday 7/15/24 | 2:30-4:30
(Required)
1230 Elm St, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45
Yes
No
Smale Riverfront Park | Monday 7/22/24 | 2:30-4:30
(Required)
166 W Mehring Way, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45
Yes
No
Mt. Echo | Monday 7/29/24 | 2:30-4:30
(Required)
251 Mt Echo Park Dr, Cincinnati, OH 45205 | Pick Up at 2:30 pm, Drop Off at 4:45 pm
Yes
No
Spruce Nails | Monday 8/5/24 | 2:30-4:30
(Required)
1818 Race St Suite 101, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45 | Your student will be getting their nails painted
Yes
No
Digital Signature of Consenting Guardian or Student (if over 18)
(Required)
By filling out your name as the parent, guardian, or consenting student (if over 18) below, you are signing in agreement with Back2Back's ability to take your child on extracurricular activities. This digital signature serves as an additional form of consent along with the choices above.
First
Last
Date of Submission
(Required)
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
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8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Name
This field is for validation purposes and should be left unchanged.
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