Medical & Liability Release Form

Student Name (first, last)

Address

City

State

ZIP

Birth Date

Date

Current Age

Current Grade

Email Address

example@example.com

Cell phone

Parent/Guardian #1 Name

Email Address

example@example.com

Cell phone

Parent/Guardian #2 Name

Email Address

example@example.com

Cell phone

Notify In Case Of Emergency

Names of authorized people to pick up in case of parents absence

Known Allergies or medical considerations

Current Medicines

Permitted to take over-the-counter Pain & Cold Medicines (Check box if yes)

Current Medicines

Insurance Company

Policy Number

Doctor's Name

Phone No.

PLEASE UPLOAD AT THE END OF THIS FORM OR EMAIL JACOB A COPY OF YOUR STUDENT'S INSURANCE CARD

Release & Hold Harmless Agreement

PLEASE READ CAREFULLY BEFORE SIGNING

In consideration for St. Peter's Episcopal Church (St. Peter's) permitting the undersigned's child to participate in its activities and events, the undersigned do hereby voluntarily agree to release and hold St. Peter's harmless, and their directors, trustees, officers, employees, leaders, and volunteers from all causes of action arising out of any negligent acts or omissions or otherwise which the undersigned and their heirs, personal representatives, administrators, assigns, guardians, wards, or successors may have against any of them for, or on account of, or by reason of the undersigned's child participation in any of the activities and events of St. Peter's. This release and hold harmless agreement specifically preclude liability on behalf of St. Peter's, their directors, trustees, officers, leaders, employees, and volunteers for any personal injury to the undersigned's child, or for damage or loss of the undersigned's personal property, which arise from or are incident tothe undersigned child's participation in any of the activities and events of St. Peter's. Specifically, by the initials of the undersigned, the undersigned further agrees to the following:

Follow the Child and Youth Protection Policy.

Consent to transportation in a personal vehicle driven by a St. Peter's staff person or approved adult to and from St. Peter's events.

Consent to the use of any video images, photographs, audio recordings, or any other visual or audio that taken of the child of the undersigned during the activity/event to be used, distributed, or as St. Peter's sees fit.

Consent to one-on-one communication between the undersigned’s child and a St. Peter’s staff personor approved adult volunteer through e-mail, text, phone or social media.

Consent for Emergency Medical Treatment

Iam the parent/legal guardian of the above named participant and I hereby authorize St. Peter's Episcopal Church and its representatives to act on my behalf in any emergency medical treatment that may be required. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required and to give specific consent to any and all such diagnosis, treatment or hospital care which a licensed physician in the exercise of his/her best judgment may deem advisable. I have read all the above-stated terms of the Release and Hold Harmless Agreement and understand its meaning fully and voluntarily agree to its terms. This authorization shall remain effective until one year from the date signed unless revoked in writing at an earlier date.

Signature of Parent/Legal Guardian

Date

Print Name Here

Student Name

Copy of Insurance Card