Medical Release

Please complete all fields on this form, including the signature box at the bottom.

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
This first section is information about the child or student who is participating at or with [CHURCH NAME].:
*Participant First Name:
*Participant Last Name:
*Gender:
*Birthdate - ex. 01/01/1980:
*Age:
*Address:
*City:
*State:
*Zip:
*Grade in Fall 2012:
Student Email:
Student Cell - ex. (661) 296-8737:
The following fields relate to the Father or Legal Guardian:
Name 1:
Cell Phone 1:
Home Phone 1:
Work Phone 1:
Email 1:
The following fields relate to the Mother or Legal Guardian:
Cell Phone 2:
Name 2:
Home Phone 2:
Work Phone 2:
Email 2:
If parents or guardians are unavailable, who should we contact?:
*Name 3:
*Relation to family:
*Phone #:
Please provide information about insurance and any medical issues we should be aware of.:
*Do you carry family medical/hospital insurance?:
If so, please indiacte carrier:
Policy #:
Name of Family Physician:
Physician's Phone #:
Name of Dentist/Orthodontist:
Dental Phone #:
Please provide information regarding any of these health issues. | Asthma | Emotional Disorder | Physical Handicap | Bleeding/Clotting Disorder | Nervous Disorder | Hay Fever | Drug/Allergies | Epilepsy | Insect Stings Diabetes | Seiz:
Health Issues - Specific Detail:
List Any Activity Restrictions:
List surgeries or serious injuries and dates:
Chronic illness, medical conditions or allergies:
Current medication (send with instruction):
*Date of last tetanus shot - ex. 01/01/1980:
Please notify [CHURCH NAME] if your child has been exposed to a communicable disease within the three weeks prior to the outing or event.:
This health information is correct so far as I know, and I expressly consent to the participant's involvement in all activities and events from [START DATE] - [END DATE], including, but not limited to, recreational activities, trips, camps, travel and act:
Although [CHURCH NAME] makes every effort to provide a safe environment, I understand that certain risks cannot be eliminated. I understand that participation in each activity and event involves inherent and other risks of Injury and Death.:
RELEASE WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT. In consideration for the participant being permitted to be involved in the activities and events from [START DATE] through [END DATE], I the undersigned, AGREE TO THE FOLLOWING::
I RELEASE, WAIVE and forever discharge [CHURCH NAME], it's Pastors, Employees, Officers, Volunteers, Board of Agents (collectively [CHURCH NAME]) from ALL LIABILITY to me, my family, heirs, assigns, personal representatives or next of kin for ANY LOSS OR:
I AGREE TO INDEMNIFY AND HOLD HARMLESS [CHURCH NAME] for any loss, liability, damage or costs incurred due to my child's participation in this [CHURCH NAME] activity.:
I ASSUME FULL RESPONSIBILITY FOR RISKS OF BODILY INJURY, DEATH OR PROPERTY DAMAGE arising from my child's participation in the [CHURCH NAME] activity.:
I further acknowledge and accept that this Assumption of Risk and Waiver is intended to be as broad and inclusive as permitted by the laws of the state in which participation takes place and agree that if any portion of this Assumption of risk and Waiver:
I HAVE READ AND UNDERSTOOD THIS 'RELEASE, Waiver of Liability and Indemnity Agreement' and have signed it voluntarily, and agree that no oral representations, agreements, or inducement, apart from the foregoing written agreement have been made. I HAVE REA:
I UNDERSTAND AND WILL ALLOW PHOTOS AND VIDEOS of my child to be taken while at any [CHURCH NAME] event and to be used in any [CHURCH NAME] presentation or publication. I also understand that publication of these photographs may be accomplished electronica:
Should [CHURCH NAME], or anyone acting on their behalf, be required to incur attorney's fees and cost to enforce this agreement, I agree to indemnify and hold [CHURCH NAME] harmless for all such fees and costs.This agreement is binding upon the participan:
By typing my first and last name in this box I am signifying that I am the parent or guardian for the child listed above and have the authority to enter into this agreement on their behalf.:
*First & Last Name:
For future verification of your identity please indicate the city and state where you were born.:
*City & State:
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