Boise Bible College Event Medical Release Form

Boise Bible College Event Medical Release Form
Guardian Name (Name of the person signing this document)*

First NameLast Name
Registered Student's Name*

First NameLast Name
Name of Event Registering For*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Doctors Name*

First NameLast Name
Primary Doctor's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Allergies*
Insurance Provider*
Policy/Group Number *
Insurance Provider Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Medication Name/Dosage/Time of Administration/OtherDetails*
Medication Name/Dosage/Time of Administration/OtherDetails (2)
Medication Name/Dosage/Time of Administration/OtherDetails (3)
Medication Name/Dosage/Time of Administration/OtherDetails (4)

I, the parent or legal gaurdian of the participant listed on this form give my permission for the He/She to participate in Boise Bible College Events.

I understand that although the students will be supervised by staff, I do assume the risk in my student's participation in the event.

I acknowledge that I will not seek to have Boise Bible College held liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of said participant's involvment in the event. This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from the student's participation in the event. I hereby release and agree to hold harmless Boise Bible College, its officials, agents and employees, from any claims arising out of sadi participants involvment in the event(s).

I allow Boise Bible College to use any photos of my student (legal dependant) for promotional or College related usages

Further, I do authorize any Boise Bible College staff member, in the event I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while on this trip. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment.

I understand that I can request a record of this form made available on paper

I understand that I have the right to withdraw consent, with the condition that consent must be withdrawn prior to your students (legal gaurdian's) arrival and attendance at the event.

To withdraw consent please contact Boise Bible College, request to withdraw your consent on your signed medical release of liability form for (Event name consented to). At which point Boise Bible College will release and withdraw your consent, as well as store, and send a copy to you of your withdrawn consent.

I understand that my consent on this form applies only to this form and this transaction

I have read and understand and accept all of the statements recited above and accept full responsibility as described.
I agree
Signature

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