MEDICAL AND LIABILITY RELEASE FORM

If any of this information should change while your child is participating in outside activities at Peninsula Baptist Church, please notify the church at 360-665-5060 or abel@peninsulabaptist.church of these changes.

Student Name*

Age

Address*

City

State

Zip

Date of Birth

Date

Parent/Guardian

First NameLast Name

Phone*

Student Cell Phone*

Please enter a valid phone number.

Other Phone

Please enter a valid phone number.

Email address

example@example.com

Doctor Name

City

Phone

Alternate Contact

Address

Phone

Allergies

Drugs

Other

Check any that apply

If you checked any of the above, please give details (i.e. include normal treatment of allergic reactions)

Last tetanus shot date of shot or mark "Current" if accurate at date of Release.

Name and dosage of any medications that must be taken

Prescription Medication must be turned in to Youth Staff if to be administered during a youth event.

Any swimming restrictions?

YesNo

Any activity restrictions?

YesNo

What Restrictions?

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 on a church related activity.

Do you have Health Insurance

YesNo

If yes, name

Policy Number

In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for the child named herein as deemed necessary.

Every activity sponsored by Peninsula Baptist Church (PBC) is carefully planned and adequately supervised by mature adults. Even with the best planning and precautions, unforeseen events or accidents can occur. By signing this form, the below indicated parent, guardian, or legal representative of the child or children named herein signifies that he or she fully understands the church activity participated in and accepts all risks and hazards inherent in such church activity.

Further, the below indicated parent, guardian, or legal representative of the child or children named herein agrees to hold harmless PBC, its employees, or volunteer assistants from any and all liability for damages, losses, or injuries to the person orproperty of any child or children named herein caused by acts or omissions amounting to simple negligence and to refrain from instituting any cause of action against any volunteer or person employed by PBC to recover losses, whether medical or otherwise arising from acts or omissions amounting to simple negligence in any court in the State of Washington.

Minor Photo Release Form

By signing this form, I am the legal guardian of the minor specified below, and I give PBC the permission to photograph my child and use his or her picture solely for the church's website, internal publications and/or social media pages. I further release and forever discharge PBC and its staff members, agents, and employees from any and all claims and demands arising out of or in connection with the use of said photographs / images, including but not limited to, any claims for invasion of privacy or defamation.

CORONOVIRUS AWARENESS AND RESPONSIBILITY

By signing I understand that PBC is committed to keeping all families safe from the spread of virus. I understand that by attending a PBC function, I and/or the minor specified am/is assuming the risk of exposure to the viruses or other public health risks. It is my responsibility to use appropriate PPE for myself and my minor dependents.

Signature*

Printed Name*

Select One

ParentGuardianLegal Representative

MEDICAL AND LIABILITY RELEASE FORM

Health History

Other Conditions

Liability Release