JCC Medical Release & Liability Form

Name:*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

School Grade*

Phone Number:*

Area CodePhone Number

Gender*

Student E-mail Address:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Name:*

First NameLast Name

Phone/Guardian Cell Number*

Area CodePhone Number

Parent E-mail Address:*

example@example.com

Medical Insurance?

YesNo

Insurance Company

Policy Number

Please list any allergies, medicines or special medical problems your child may have/take *

I attend a local church:

Regularly (most weeks)Occasionally (few times a year)Never (or almost never)

I understand that this medical and liability release covers all Jenison Christian Church activities. I understand that this medical and liability release covers my child until he/she graduates from high school or until he/she turns 18 years old, whichever is later.

I understand that authorization and permission is hereby given to Jenison Christian Church to furnish and necessary transportation, food and lodging for this participant. I hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Jenison Christian Church. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all transportation costs.

I understand that in the event medical intervention is needed, a reasonable attempt will be made to contact the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia or surgery for my child as deemed necessary.

I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Jenison Christian Church through its accident policy is a back up for what my family's insurance does not cover.

I understand that reasonable safety precautions will be taken at all times by the Jenison Christian Church and its agents. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I indemnify and agree not to hold Jenison Christian Church, its leaders, employees and volunteers liable for damages, losses, diseases or injuries incurred by the subject of this form.

Submission of this form electronically requires the use of a digital signature. By signing , I agree that my digital signature on this form has the same legal effect as my manual signature (in accordance with the ESIGN Act).

Parent/Guardian Signature*

Date

Signature of Participant (If over 18)