Combined Release and Medical Form

This form is a combined RELEASE FORM for youth and children activities taking place outside of the church. This form must be agreed upon and submitted prior to the event. This form must be filled out by the PARENT or LEGAL GUARDIAN of the participant. Any other person submitting this form is considered a fraudulent activity.

Name of Participant*

Age*

Name of Event*

Agreement*

Yes. I agree to the statement below.

In case of medical or surgical emergency, I hereby give my permission to the physician selected by the leaders in charge of the trip to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for me as named above. I agree to be transported in private or public vehicles provided by the church. I understand that, by checking the above box, this serves as a digital signature and official agreement to this statement.

Parent or Legal Guardian Name

First Name

Last Name

Mobile Phone*

Mobile Phone Carrier

This is needed for free text communications. Ex: Sprint... Verizon... T-Mobile...

Email

Medical Insurance Company*

Medical insurance Policy Number*

Emergency Contact Name*

This procedure will be followed only under necessary circumstances. Normal procedure would be to attempt to contact the parent/legal guardian, listed above, first.

Emergency Contact Name*

First Name

Last Name

Emergency Contact Relationship*

Emergency Contact Phone Number*

Participation Agreement*

I agree to the following statement.

In return for the acceptance of my CHILD’S application and participation, I, (The Parent or Legal Guardian listed above), do for myself, my heirs and personal representatives of my estate, release SECOND PRESBYTERIAN CHURCH, its agents and successors, from any and all claims for damages which I may have now or in the future as a result of my participation in any CHURCH activity. In doing so, I agree to assume all risks of loss as may reasonable be expected to arise in connection with my participation in any CHURCH activity. Should any part of this release be found invalid or unenforceable, the remaining provisions shall remain valid and enforceable.

Release Agreement*

I agree to the following statement.

Parents' or Legal Guardian agreement required if participant is still supported by parents, and/or living at home. As parent or legal guardian of the participant, I also hereby agree to release, and indemnify and hold harmless SECOND PRESBYTERIAN CHURCH for any claims which may be brought by us or by the participant against SECOND PRESBYTERIAN CHURCH as described above.

Photo/Video Release Agreement*

I agree to the following statement.

I grant to SECOND PRESBYTERIAN CHURCH, its representatives and employees the right to take photographs or video of my child and his/her property in connection with the above-identified event. I authorize SECOND PRESBYTERIAN CHURCH, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that SECOND PRESBYTERIAN CHURCH or PC (U.S.A.) may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Date/Time

:

Digital Signature*

By typing my name in the above box, and submitting this form using the button below, I understand that this is a legally binding agreement upon submission receipt.

Medications*

Yes No

Does the participant take any medications?

Medication details

Please include name of medication(s), dosage and time(s) to be taken.

Diabetes*

Yes No

Is the participant diabetic?

Diabetes details

Please give any details or treatments necessary.

Seizures or reactions*

Yes No

Does the participant have a history of seizures or reactions to medications?

Seizure or reaction details

Please give any details or treatments necessary.

Asthma*

Yes No

Does the participant have a history of asthma?

Asthma details

Please give any details or treatments necessary.

Allergies*

Yes No

Does the participant have any allergies?

Allergy details

What is the nature of the allergy? Please give any details or treatments necessary if a reaction occurs.

Dietary Restrictions*

Yes No

Does the participant have any allergies?

Dietary Details

What is the nature of the restriction? Please make suggested alternatives.