Medical and Liability Release Form Student Name * First Name Last Name Student Date of Birth * Student Grade * Student Current School Student Phone * (###) ### #### Parent or Guardian Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent or Guardian Phone * (###) ### #### Parent or Guardian Email * Parent or Guardian Name (2) Parent or Guardian Phone (2) (###) ### #### Additional Emergency Contact In an emergency when parent/guardian cannot be reached, please contact the following: Name Phone (###) ### #### Relationship to Student Health History Allergies * Please identify any allergens (including foods), health problems, medications, or other health concerns below. Insect Bites Food Medicine Other None Other Health Concerns (specify) If checked any of the above please explain here. Other Conditions * Heart Condition Frequent Colds Frequent Stomach Aches Hay Fever Diabetes Physical Handicap Asthma Epilepsy Other (Please Specify Below) None Other Conditions (Specify) Date of last Tetanus if applicable MM DD YYYY Can student swim? Yes No Any swim restrictions? Yes (Please specify below) No Swimming Restrictions Insurance Information 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 your son or daughter is involved in church-related activities. Do you have health insurance? * Yes No Name of Insurance Provider Provider Phone Number Policy Number Claims Number Claims Address Statement of Release Every student ministry activity sponsored by this church is carefully planned and supervised by mature adults. However, even with the best planning and precaution, unforeseen events can occur. The parent or guardian agrees to assume and accept all risks and hazards inherent in church-related activities by signing this form. He or she agrees not to hold Citylight Council Bluffs or its employees or volunteer assistants liable for damages, losses, or injuries to the person named above. He or she also understands that the signature below is for both a medical and liability release. "In the event that I (the parent or legal guardian) can not be reached in an emergency, I hereby give permission to the physician or dentist selected by Citylight Council Bluffs leadership to hospitalize, secure proper treatment, and/or order an injection, anesthesia, or surgery for the person named above as deemed necessary. I also agree to accept full financial responsibility for the cost of such treatment." Acknowledgement I understand that this is a legal agreement binding upon myself and my heirs, executors, administrators, successors, and assigns. I have read and understood the terms of this agreement, and I acknowledge that by signing this agreement voluntarily, I agree to abide by its terms, and I am waiving certain legal rights that my child or I may have. Acknowledgement Verification * I understand and agree with the acknowledgement above. Electronic signature of parent or guardian (if participant is under 18 years of age) * Date of Signature * MM DD YYYY Electronic Signature of Student * Date of Student Signature MM DD YYYY Thank you!
