Foothill Church Medical and Liability Release Form

Foothill Church Medical and Liability Release Form

This form must be filled out completely in order for your student to accompany Foothill Church staff or volunteers on any off-campus excursions.
Student's Name*

First NameLast Name
Student's Age*
Student's Grade*
(Or incoming grade in the summer)
Parent or Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Email*
example@example.com
Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Student's Gender*
Student's Date of Birth*

MonthDayYear
Date
In case above number does not answer, please notify:
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Doctor Name*
Doctor Phone Number*
Please enter a valid phone number.

Health History
Allergies*
If none please write N/A
Other Conditions
i.e.: Heart Condition, Frequent Colds, Asthma, Diabetes, hay Fever, Frequent Stomach Upsets, Epilepsy, Physical Handicap
If you filled out above, please give details (I.e. include normal treatment of allergic reactions)
Date of last tetanus shot*

MonthDayYear
Date
Name and dosage of any medications that must be taken
Any swimming restrictions*
Any activity restrictions*
Please Explain Restrictions

Insurance

Foothill Church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church related activity.
Do you have health insurance?*
If you DO NOT have health insurance please fill out the additional medical insurance waiver on the bottom of this form.
Name and address of health insurance
Policy Number

Medical and Liability Release
In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospialize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter.
Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforseen events can occur. By signing this form, the parent/guardian agrees to assume and accept all risks and hazards inherent in church related activities. They also agree not to hold this church or its employees or volunteer staff liable for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are signing for a minor listed on this form and the signature is both a medical and liability release.
Parent or Guardian's Signature*

Clear
Date*

MonthDayYear
Date

MEDICAL INSURANCE WAIVER (Only for those without insurance)

Valid Through December 31, 2024
(Student)First Name Last Name has no medical insurance. I/We (Parent/Guardian), First Name Last Name accept full responsibility for any medical expenses incurred as a result of accident or injury that occurs during a FOOTHILL CHURCH sponsored youth activity.
Parent/ Guardian Signature

Clear
Date

MonthDayYear
Date

Thank you for filling out this form, and we are excited to see your student soon!
Should be Empty:

In case above number does not answer, please notify: