Medical and Liability Release Form

Medical and Liability Release Form

Gethsemane Church of Christ 5146 Mechanicsville Turnpike Mechanicsville, Va. 23111
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Parent/Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Information
Name*

First NameLast Name
Relationship*
Cell Phone*

Area CodePhone Number
Name

First NameLast Name
Relationship
Cell Phone

Area CodePhone Number
Insurance/Doctor's Information
Do you have health insurance?*

YesNo
Insurance Company
Policy Number
Doctor's Name
Medical Information
Allergies?*

YesNo
If Yes, list allergies
Medications?*

YesNo
If Yes, list medications
Any trouble with heat stroke/exhaustion?*

Yes to allNo to allYes Heat StrokeYes Exhaustion
Any trouble with high blood pressure?*

YesNo
May your child have Tylenol or Benadryl?*

Yes to allNo to allOnly TylenolOnly Benadryl
Date of last tetanus shot*
Any additional medical information we should be aware of?
Authorization of Consent for Treatment of Minor
I, the undersigned parent of guardian of the above stated child, a minor, do hereby authorize for duly authorized employee, volunteer, or other representative of the Gethsemane Church of Christ, agent(s) for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general of specific supervision of, any licensed physician and surgeon or at a clinic, hospital or other medical facility.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but it is given to provide authority and power on the part of the aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician is the exercise of his or her best judgement may deem advisable.

I, the undersigned, on behalf of myself and the above mentioned student, shall indemnify, hold free, and harmless, assume liability for and defend Gethsemane Church of Christ, its agents, servants, employees, officers, and directors from any and all costs expenses, including but not limited to attorneys' fees, reasonable investigative and discovert costs, court costs, and all other sums, which Gethsemane Church of Christ, it's agents, servants, employees, officers, and demand for, claim or assertion or liability, or any claim or action founded therein, arising or alleged to have arisen out of my child's use of real or personal property belonging to Gethsemane Church of Christ, it's agents, servants, employees, officers, and directors, or by reason of my child's participation in any Gethsemane Church of Christ activities.
Permission for my student to participate in off-site events, activities or trips.
My student is allowed to attend events sponsored by Gethsemane Church of Christ that take place off campus, and my student is allowed to to be transported to these events by a Gethsemane Church of Christ church bus/van, or volunteers authorized to drive their personal vehicles for the specific event. I understand the nature of these events, and I will not hold Gethsemane Church of Christ liable for any injury or accident that happens to my student during and event.
Permission for my student to be photographed.
My child is allowed to be photographed while participating in events and activities sponsored by Gethsemane Church of Christ's Student Ministry. I understand that these photos could be displayed on bulletin boards at Gethsemane Church of Christ, or used in any Gethsemane Church of Christ publicity, including any associated internet websites.
I have read the above statements, and by signing below electronically I agree to said statements.
Parent or legal guardian signature*

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Should be Empty:

Medical and Liability Release Form

Emergency Contact Information

Insurance/Doctor's Information

Medical Information

Authorization of Consent for Treatment of Minor

Permission for my student to participate in off-site events, activities or trips.

Permission for my student to be photographed.