Nextwave Medical Release Form (Parent)

Nextwave Medical Release Form (Parent)

Each student missionary, staff member, and volunteer must fill out the information below completely. This form will be kept on file for one (1) year as a medical release. If your medical or insurance information changes, please contact your trip or program leader or submit another online form to update your information.
What is the name of the church that your student attends?
Student's Name*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Age*
School*
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please least any known allergies the student has, including allergies to food or medicine:*
If none, please type "N/A"
Date of last Tetanus shot:*

MonthDayYear
Date
Can this student take Tylenol or Ibuprofen?*

YesNo
Do you grant permission to SALT Next Gen staff to treat minor injuries, if deemed necessary?*

YesNo
Is there any other information we should need to be aware of regarding the physical condition of this student prior to participating in this trip or ministry opportunity?*
If non, please type "N/A"
Parent / Guardian Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Emergency Contact (If parents cannot be contacted)*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Insurance Info
Is this student covered by health insurance?*

YESNO
Please provide the name of your student's health insurance provider:
Who is the primary insurance holder on this policy?
Policy number and/or group number:
Please provide a photo or your insurance card:
Release
I hereby give my permission, for myself or my child, to participate in an activity organized by Nextwave Missions. I hereby release, hold harmless and absolve Nextwave Missions, their officers, staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Nextwave Missions staff or any adult counselor acting on behalf of Nextwave Missions with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate} licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child's medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that Nextwave Missions may tape or photograph my child and record his or her Voice during their participation in the activity. I agree that Nextwave Missions will be able to use them, in whole or in part. whether In original or modified form in any manner or media, Including without limitation, for the purpose of advertising, promoting, and publishing the Nextwave Missions whether doing the activity or thereafter. I hereby release and discharge Nextwave Missions and an affiliated entities from any and all claims, demands, or causes of action that I shall in connection with the use and exercise of the rights granted in this release.
Signature*

Clear
Parent / Guardian
Submitted Date*

MonthDayYear
Date
Should be Empty:

Nextwave Medical Release Form (Parent)

Insurance Info

Release