NCC Student Ministries Release Form

NCC Student Ministries Release Form

Medical Information and Liability Release for Student Ministries Events
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Date of Birth:

MonthDayYear
Date
Father's Name:
Father's Contact Number:
Please enter a valid phone number.
Mother's Name:
Mother's Phone Number:
Please enter a valid phone number.
Other Contact Name:
Other Contact's Phone Number:
Please enter a valid phone number.
Medical Information
Medical Insurance Company Name:
Name of Policy Holder:
Policy Number:
Please list all known Medication Allergies, Other Allergies or Medical Conditions:
Medical and Liability Release:

Please read carefully and sign below:
I grant Ninevah Christian Church, its staff, members, workers, and volunteers permission to seek medical treatment for my child in the event that he/she requires medical treatment while participating in any activity with Ninevah Christian Church.
I grant permission for my child to attend and participate in the planned activities at/with Ninevah Christian Church. I agree to release and hold harmless any staff, member, worker, and volunteer of Ninevah Christian Church who transports my child in any vehicle to a designated youth event.
Signature of Parent/Guardian:

Clear
Should be Empty:

Medical Information