Fulton Church Consent and Release Form

Name of Participant

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Date of Birth

Date

Family Doctor

Insurance Company

Insurance Company Phone Number

Please enter a valid phone number.

Insurance Policy Number

List any specific medical allergies, chronic illnesses, or other conditions.

Medicines taken and prescription directions

Phone Number I may be reached in emergency

Please enter a valid phone number.

Other emergency contact

Emergency Contact Phone Number

Please enter a valid phone number.

Date of last tetanus shot

Date

I do not wish my child to participate in the following...

I the undersigned parent or guardian hereby consent to my child, blanks to participate in . At blank on Date . I confirm that my child is able to participate in this event. If my child has medical conditions which, in the event of an emergency, may be relevant to a physician, I have listed them below. In the event of an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize First Name Last Name , (an adult sponsor or leader) to make emergency medical decisions for my child. If there are any activities, I don't want my child to be involved in, I have listed them below.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THESE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITY, INCLUDING
ACTIVITIES PRELIMINARY AND SUSEQUENT THERETO. I do hereby agree to hold Fulton Church and its agents and employees, harmless from any and all liability, actions, cause of actions, claims, expenses, and damages on account of injury to my child or property even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the state of Wisconsin and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understand.

Signature

Date