Medical Release Form

Medical and Liability Release Form

Gethsemane Church of Christ

5146 Mechanlcsville Turnplke Mechanlesville, VA

STUDENT'S NAME

ADDRESS

CITY

STATE

ZIP

HOME PHONE

BIRTHDAY

GRADE

PARENT/GUARDIAN'S NAME(S)

Mom (Home Phone)

Dad (Home Phone)

Mom (Work Phone)

Dad (Work Phone)

Mom (Mobile Phone)

Dad (Mobile Phone)

NAME

PHONE

RELATIONSHIP

NAME

PHONE

RELATIONSHIP

DO YOU HAVE HEALTH INSURANCE?

YESNO

INSURANCE COMPANY

POLICY NUMBER

DOCTOR'S NAME

PHONE

ALLERGIES

YESNO

Allergies

Medications:

YESNO

Medications

Medical Restrictions?

YESNO

Restrictions

Heat Stroke/Exhaustion?

YESNO

High Blood Pressure?

YESNO

Is your child allowed to have Tylenol/Acetaminophen?

YESNO

DATE OF LAST TETANUS SHOT

Date

Any additional relevant information?

YESNO

ANY ADDITIONAL RELEVANT INFORMATION?

Authorization of Consent for Treatment of Minor/ Permission to participate in

off-site activities/ Permission to be photographed

I, the undersigned parent or guardian of (Student's name), a minor, do hereby authorize any duly authorized employee, volunteer or other representative of the Gethsemane Church of Christ, as 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 or specific supervision of, any licensed physician and surgeon, whether such diagnosis or treatment is rendered at the office of sald physician and surgeon or at a clínic, 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 Is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his or her best judgment may deem advisable.

I, the undersigned, on behalf of myself and (student's name), 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 and expenses, Including but not limited to attorneys' fees, reasonable investigative and discovery costs, court costs and all other sums, which Gethsemane Church of Christ, Its 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, its agents, servants, employees, officers, and directors, or by reason of my child's participation in any Gethsemane Church of Christ activities.

My student Is allowed to attend events sponsored by Gethsemane Church of Christ that take place off campus, and my student Is allowed to be transported to these events by a Gethsemane Church of Christ church bus, 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 Ilable for any injury or accident that happens to my student during an event.

Permission for my student to participate in off site events, activities or trips (Please Initial box)

Permission for my student to be photographed (Initial one of the two options below): 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, induding any associated Internet websites.

My child is allowed to be photographed while participating in events and activities sponsored by Church of Christ's Student Ministry. I understand that these photos could be displayed on boards at Gethsemane Church of Christ, or used in any Gethsemane Church of Christ publicity, any associated Internet websites. (Please Initial Here)

My child is not allowed to be photographed while participating in events and activities sponsored by Church of Christ's Student Ministry. (Please Initial Here)

This authorization shall be in effect from

Parent or Legal Guardian Signature

Date

EMERGENCY CONTACTS

INSURANCE/DOCTOR'S INFORMATION

OVER