Adult Medical Release & Activity Permission 2018-2019
Name
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First Name
Last Name
I will participate in overnight and off-site activities with St. Paul's Youth Ministry. I understand that some of these activities involve travel in privately owned vehicles driven by adult volunteers or parish employees. I do hereby hold harmless and release St. Paul’s Episcopal Church, Cary, and all adult volunteers and employees from any liability in the event of any accident, injury, or loss of personal property involving me during this activity.In the event of a medical emergency, I understand that every reasonable effort will be made to contact my emergency contacts at the phone numbers listed below. In the event that we are unable to make arrangements for emergency medical treatment for me, I authorize any adult volunteer or parish employee associated with the Sunday School or Youth Group activity to consent to all necessary medical care deemed necessary. I also understand that payment for such services is my responsibility.
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Yes
No
Electronic Signature
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Date
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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Area Code
Phone Number
Medical Insurance Company
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Contact for Authorization
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Policy Number
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Allergies, Medical Conditions, Restrictions, Special Needs:
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Any other information for adult leaders to know about you?
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