Medical & Liability Release Form
All Saints Episcopal Church of Jacksonville
Student Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth date
-
Month
-
Day
Year
Date
Current Age
Preferred Shirt Size
Adult Sizes only
School
Current Grade
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Parent/Guardian #1 Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Parent/Guardian #2 Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Notify In Case Of Emergency
Names of Authorized people to pick up incase of parents absence
Known Allergies or Medical considerations
Medication
Permitted to take over-the-counter Pain & Cold Medicines (Check box if yes)
Current Medicines
Insurance Company
Policy Number
Doctor's Name
Phone Number
Please enter a valid phone number.
PLEASE UPLOAD AT THE END OF THIS FORM OR EMAIL MARISSA A COPY OF YOUR STUDENT'S INSURANCE CARD
Release & Hold Harmless Agreement
PLEASE READ CAREFULLY BEFORE SIGNING. In consideration for All Saints Episcopal Church (“All Saints”) permitting the undersigned's child to participate in its activities and events, the undersigned do hereby voluntarily agree to release and hold harmless All Saints and their directors, trustees, officers, employees, agents, leaders, and volunteers (“Releasees”) from all claims and causes of action arising out of any negligent acts or omissions or otherwise which the undersigned and/or their heirs, children, personal representatives, administrators, assigns, guardians, parents, wards, or successors may have against any of the Releasees in connection with the undersigned's child’s participation in any of the activities and events of All Saints. This release and hold harmless agreement specifically preclude liability on behalf of any Releasee 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 to the undersigned child's participation in any of the activities and events of All Saints. Specifically, by the initials of the undersigned, the undersigned further agrees to the following:
Follow The Episcopal Church model and policy for the protection of Children and Youth.
Initial
Consent to transportation in a personal vehicle driven by a All Saints staff person or approved adult to and from All Saints events.
Initial
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 All Saints sees fit.
Initial
Consent to one-on-one communication between the undersigned’s child and a All Saints staff person or approved adult volunteer through e-mail, text, phone or social media.
Initial
Consent for Emergency Medical Treatment
I am the parent/legal guardian of the above named participant and I hereby authorize All Saints 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
-
Month
-
Day
Year
Date
Print Name Here
Student Name
Copy of Insurance Card
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