Please note: LEAD Four:Twelve staff are not responsible for dispensing medicine.
My child has my permission to attend all LEAD Four:Twelve (a ministry of the Jeremiah Project) retreat and events. In the case of a medical emergency, I understand that every effort will be made to contact my child's parent(s) or guardian(s). In the event that neither I, nor the emergency contact person listed above, can be located, I hereby give permission for the LEAD Four:Twelve Coaches/Leaders with consultation from the on-site RN to select a physician, to hospitalize, to secure proper treatment for, and to order injection, anesthesia or surgery for my child. (This information will be required in the event that the participant listed above is taken for medical treatment.) Jeremiah Project insurance serves as a secondary coverage. I release the following from any liability in the event of an accident or injury en route to, during and/or returning from LEAD Four:Twelve activities, both work and recreational related: The Jeremiah Project, Inc. and all staff persons connected within, all adult leaders, chaperones, and/or churches.
Please confirm the accuracy of your answers before submitting this form!
Note to Parents/Guardians: If any of this information changes while your student is in LEAD 4:12 you will need to fill out a new medical form. Please also email email@example.com to ensure we have updated your student's medical form.