Participation and Medical Release 2024

Bear Valley Community Church Participation & Medical Release 2024

Each student participant must have his/her parent/guardian complete this form. If you have multiple students, please fill out a separate form for each one.
Student Information
Student Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number

Area CodePhone Number
Parent/Guardian Information
Name

First NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Participant's Medical Information
Name of Insurance Policy Holder
Insurance Provider
Policy Number
Group Number
Phone Number

Area CodePhone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe and fill out a Medical Instruction Form at event check-in.
Does the student have any social or behavioral issues we should know about? If yes, please describe.
Medical Release and Authorization

The undersigned is the parent or legal guardian of the minor named above (Minor). The undersigned guardian desires for said Minor to attend and/or participate in ministries, events, programs, functions, and activities (hereafter referred to as “activity”), sponsored by, connected with, or related to Bear Valley Community Church, a Texas not-for-profit corporation (Church).

I understand and acknowledge that the Church will not allow the minor to participate in any Church Activity without releasing and holding the Church harmless from any liability arising out of the Minor’s attendance and/or participation in that Activity, including the Minor’s transportation to and from the Activity provided by the Church. I have or will investigate all risks involved with the Minor’s attendance and/or participation in the Activity, and further as the parent or legal guardian of said Minor assume any and all risks of personal or bodily injury to said Minor or property damages associated with said Activity.

By signing this document, on behalf of myself and the Minor, I hereby release and forever discharge the Church, its officers, directors and employees, agents and any parties volunteering on behalf of the Church from all claims, damages, costs, or expenses of any kind arising out of or related to the Minor’s attendance or participation in any Church Activity. I understand that this document is a full complete Release of all claims for personal or bodily injury and property damage which the Minor might sustain as the results of the Minor’s attendance and/or participation in any Church Activities, regardless of the specific cause thereof, and I further understand that in the event of such personal bodily injury to the minor, or property damage, that I cannot seek, on behalf of the Minor or myself, any type of recovery or reimbursement whatsoever from the Church or their officers, directors, employees, agents or any parties volunteering on behalf of the Church.

By signing this document, on behalf of the Minor and myself, I hereby give release for any medical attention to be administered in the event medical attention is required.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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Bear Valley Community Church Participation & Medical Release 2024

Emergency Contact Information

Participant's Medical Information