Medical Release

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

Participant Information
This first section is information about the child or student who is participating at or with Grace Baptist Church.
*Participant First Name
*Participant Last Name
*Gender
*Birthdate - ex. 01/01/1980
*Age
*Address
*City
*State
*Zip
*Grade in Fall 2013
Student Email
Student Cell - ex. (661) 296-8737
Father/Male Guardian 1
The following fields relate to the Father or Legal Guardian
Name
Cell Phone
Home Phone
Work Phone
Email
Mother/Female Guardian
The following fields relate to the Mother or Legal Guardian
Name
Cell Phone
Home Phone
Work Phone
Email
Alternate Contact
If parents or guardians are unavailable, who should we contact?
*Name
*Relation to family
*Phone #
Health & Insurance Information
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 #
Health Issues
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 | Seizure Disorder | Cardiac | Any other issues |
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
IMPORTANT:
Please notify Grace Baptist Church (GBC) if your child has been exposed to a communicable disease within the three weeks prior to the outing or event.
Authorization A
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 September 1, 2013 - August 31, 2014, including, but not limited to, recreational activities, trips, camps, travel and activities sponsored by Grace Baptist Church. The participant agrees to comply with all rules and policies for each activity and event.
I authorize any person connected with Grace Baptist Church on any activity or event to administer first aid to the participant, as they deem necessary. I authorize medical and surgical care and transportation to medical facility or hospital for treatment necessary for the participant's well-being, at my expense. I authorize the supervisors of the activity to carry out any discipline deemed necessary for my child. I also agree, if necessary, that I will pay the expenses of my youth being sent home because of a disciplinary action.
Acknowledgment of Risks
Although Grace Baptist Church 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.
Introduction
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 September 1, 2012 through August 31, 2013, I the undersigned, AGREE TO THE FOLLOWING:
Part 1
I RELEASE, WAIVE and forever discharge Grace Baptist Church, it's Pastors, Employees, Officers, Volunteers, Board of Agents (collectively Grace Baptist Church) from ALL LIABILITY to me, my family, heirs, assigns, personal representatives or next of kin for ANY LOSS OR DAMAGE RESULTING FROM PHYSICAL OR MENTAL INJURY, DEATH OR PROPERTY DAMAGE arising from my child's participation in this Grace Baptist Church activity. I PROMISE NOT TO SUE Grace Baptist Church from any claim that is released under this Agreement.
Part 2
I AGREE TO INDEMNIFY AND HOLD HARMLESS Grace Baptist Church for any loss, liability, damage or costs incurred due to my child's participation in this Grace Baptist Church activity.
Part 3
I ASSUME FULL RESPONSIBILITY FOR RISKS OF BODILY INJURY, DEATH OR PROPERTY DAMAGE arising from my child's participation in the Grace Baptist Church activity.
Part 4
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 is deemed invalid, the remainder will continue in full legal force.
Part 5
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 READ AND UNDERSTOOD THIS "RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT" AND AGREE TO IT.
Part 6
I UNDERSTAND AND WILL ALLOW PHOTOS AND VIDEOS of my child to be taken while at any Grace Baptist Church event and to be used in any Grace Baptist Church presentation or publication. I also understand that publication of these photographs may be accomplished electronically via the Internet/ Worldwide Web and that after publication, the church will be unable to prevent persons from gaining access to the Internet/Worldwide Web, copying my photographs and video there from, and subsequently using, altering or republishing them without my consent. I waive any claim for damages against the Grace Baptist Church from unconsented use, alteration or, republication of my photographs and video by third parties accessing the Internet/Worldwide Web.
Part 7
Should Grace Baptist Church, 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 Grace Baptist Church harmless for all such fees and costs.This agreement is binding upon the participant's heirs, executors, administrators, and assigns. I acknowledge this agreement is governed by the applicable laws of the State of California. If any provision of this agreement is held in whole or in part to be unenforceable for any reason, the remainder of that provision and of the entire agreement will be severable and remain in effect. I HAVE READ, UNDERSTAND AND VOLUNTARILY AGREE TO THIS LIABILITY RELEASE, MEDICAL RELEASE, WAIVER, CONSENT AND RELEASE OF LIABILITY, THE DISCLAIMER, ASSUMPTION OF RISK AND WAIVER AND ACKNOWLEDGEMENT AND CONSENT AGREEMENTS, FULLY UNDERSTAND THE TERMS OF EACH, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY MY SIGNING THIS FORM AND AGREEING TO THESE TERMS, AND I SIGN THIS FORM AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT OF ANY KIND. FURTHERMORE, I AGREE TO INFORM GRACE BAPTIST CHURCH IN A TIMELY MANNER IF ANYTHING ON THIS FORM OR ITS ATTACHMENTS CHANGES.
Signature
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
Verification
For future verification of your identity please indicate the city and state where you were born.
*City & State


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