STUDENT’S NAME ______________________________ BIRTHDATE ___________ AGE _____
ADDRESS ________________________________ CITY _________________ ZIP _________
EMAIL ____________________________________ GRADE LEVEL __________
PARENTS’/GUARDIAN NAMES ____________________________________________________
HOME PHONE ________________ WORK PHONE ________________ CELL _______________
Local emergency contact (in case parents are out of town)
NAME _______________________________ PHONE ______________________
HEALTH HISTORY (please explain any conditions we should be aware of):
Allergies (insect stings, medications, food, etc.):
Name/Dosage of medications currently taking:
Blood Type _______
Any other conditions (heart, diabetes, asthma, epilepsy, etc.)
Last tetanus shot: ___/___/___ Swimming restrictions?
What restrictions? _________________________
Every activity sponsored by Community Church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, you agree to assume and accept all risks and hazards inherent in church-related social and sport activities including transportation to and from activities. You also agree that you will not hold Community Church or its employee or volunteer assistants liable for damages, losses or injuries to the person names on this form. You understand that this form and your signature are for both medical and liability release.
Minor’s Liability Release
I give permission for my child, ____________________________, to participate in all activities as part of the ministry of [Community Church of Anytown, AnyState.] As parent or legal guardian of said minor, I accept full responsibility for any medical costs incurred in the event of an accident or other incident requiring medical treatment. I release Community Church from any liability, in the event of an emergency in which my child is in need or immediate hospitalization, medical attention or surgery, and after reasonable efforts have been made to contact me or my spouse and we cannot be located for the purpose of consenting thereto, consent for the emergency attention may be given to any person standing in loco parentis to my child. It is understood that my child will obey all regulations and follow instructions of the leaders. I agree to pay any expenses including the cost of my son/daughter being sent home if discipline is deemed necessary.
The above Liability and Medical Release covers any and all activities sponsored by or associated with Community Church.
Our church’s insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while participating in activities or on the church premises.
Medical Insurance Company Name_________________________________
Policy #_________________________ Address_________________________ Phone (____)__________________
Print Name______________________ Date:_________________________
Community Church * 123 Anystreet Lane * Anytown, Any State * Zip Code * (000) 000-0000