JCT7 Registration Form & Medical and Liability Release Form

JCT7 Registration Form & Medical and Liability Release Form

Please fill out a separate form for each participant. Next session runs on Saturdays, 9-11 am, September 27-November 8.
Participant's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate:

MonthDayYear
Date
Grade:
MaleFemale
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact:
Name: name Phone: phone Relationship: relationship
Emergency Contact:
Name: name Phone: phone Relationship: relationship
Emergency Contact:
Name: name Phone: phone Relationship: relationship
INSURANCE/DOCTOR’S INFORMATION

THE CHURCH’S INSURANCE IS ONLY SECONDARY INSURANCE. IF YOU HAVE MEDICAL INSURANCE, YOUR CARRIER WILL BE BILLED FIRST FOR MEDICAL CHARGES IN THE CASE OF ILLNESS OR INJURY.
YesNo
Insurance Company:
Policy Number:
Doctor's Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Health Information:
YesNo
If allergies, what?
YesNo
If medications, what?
YesNo
If restrictions, what?
Any trouble with:
YesNo
YesNo
YesNo
Date of last tetanus shot:
Any additional health information?
Authorization of Consent for Treatment of a Minor

I, the undersigned parent or guardian of
child's name , a minor, do hereby authorize any duly authorized employee, volunteer or other representative of Gethsemane Church of Christ, as agent(s) for the undersigned, to consent to any examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of, any licensed physician and surgeon or at a clinic, hospital or other medical facility.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his or her best judgment may deem advisable.

This authorization shall be in effect from JANUARY 2025 to DECEMBER 2025.
I, the undersigned, on behalf of myself and
child's name , shall indemnify, hold free and harmless, assume liability for and defend Gethsemane Church of Christ, its agents, servants, employees, officers and directors from any and all costs and expenses, including but not limited to attorney’s fees, reasonable investigative and discovery cost, court costs and all other sums, which Gethsemane Church of Christ, its agents, servants, employees, officers and demand for, claim or assertion or liability, or any claim or action founded therein, arising or alleging to have arisen out of my child’s use of real or personal property belonging to Gethsemane Church of Christ, its agents, servants, employees, officers, and directors, or by reason of my child’s participation in any Gethsemane Church of Christ activities.
Parent or Legal Guardian Signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

JCT7 Registration Form & Medical and Liability Release Form

INSURANCE/DOCTOR’S INFORMATION

Health Information:

Any trouble with: