Release of Liability/Medical Form
Legacy Christian PSP
Which campus will your student be attending? Check all that apply
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Chino Hills Fridays
Rancho Cucamonga Tuesdays
Rancho Cucamonga Thursdays
Cross Light Rancho Cucamonga Thursdays
Chino Hills Wednesdays
The Heights
Shepherd of the Hills
Student Name
First Name
Last Name
Student Date of Birth
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Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Mother's Cell Phone Number
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Family Doctor
First Name
Last Name
Doctor Phone Number
Please enter a valid phone number.
Doctor City
Father's Cell Phone Number
Please enter a valid phone number.
Allergies
Insect bites
Medicine
Food
Asthma
Other
Release of Liability
I/We the Parent/Guardian of student listed above understand and acknowledge that by consenting to allow my child to participate in school activities, I shall by law, be deemed to have given up all claims against Legacy Christian PSP (herein mentioned as Legacy) and each of its overseers for any injury, accident, illness or death that may arise out of, enroute to, enroute from, in residence or as a result of any involvement or participation in activities sponsored by Legacy including ASB events. I agree to release Legacy, the staff, employees and volunteers of Legacy of any responsibility for damage or loss of my child’s property occurring during or by any reason of the outing/event. In the event of any illness or injury, I hereby consent to whatever x-ray. examination, anesthetic, medical, dental or surgical diagnosis or treatment or hospital care from a licensed physician and /or surgeon deemed necessary for the safety and welfare of my child. It is understood that the resulting expense will be the responsibility of the parent(s), or guardians(s) or participant. (Whenever possible attempts will be made to contact the parent/guardian prior to taking any medical action). This waiver of liability will remain effective until June 1, 2025 unless revoked in writing by the undersigned and delivered to Legacy Christian PSP.
Parent Name
First Name
Last Name
Date
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Month
-
Day
Year
Date
Parent Signature
Submit
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