South Arlington Church of Christ
Medical Release Form
Effective June 1st, 2009 thru June 24th, 2010
THIS FORM SHALL REMAIN EFFECTIVE UNTIL June 24th, 2010.
Please print, sign, and return this form.
_________________________________________
Student’s Name
Release of Liability for all Youth Group Events
I hereby release, forever discharge and agree to hold harmless South Arlington Church of Christ, its ministers, directors, employees and volunteers, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above named child that occur during any activities. Furthermore, I hereby assume all risk and personal injury, sickness, death, damage and expense as a result of participation in these activities. The undersigned further agrees to hold harmless and indemnify South Arlington Church of Christ, its ministers, directors, employees or volunteers, for any liability sustained by said church as the result of the negligent, willful or intentional acts of the above named child, including expenses incurred attendant thereto. I,__________________, parent or legal guardian of herein authorize the adult sponsor of South Arlington Church of Christ, Arlington, TX, to consent to any X-ray, examination, anesthetic, medical or surgical supervision and on the advice of any physician or surgeon licensed to practice in the state of treatment, when the need for such treatment is immediate, and when efforts to contact me are unsuccessful. This authorization shall remain effective until September 30, 2010.
__________________ /__________________
Signature of Parent or Guardian / Printed name and Date
PERSONAL INFORMATION
Student’s Full Name: _____________________
Home Address: _________________________
_____________________________________
City: Zip Code: _________________________
Home Phone: (______ ) ___________
Student’s E-Mail:_______________________
Parent E-mail: ________________________
Gender: ____ Birth Date: __________________
School: ______________________ Grade: ____ .
Mom’s Name: _________________________
Mom’s Work Phone:( _____ ) _____________
Dad’s Name: __________________________
Dad’s Work Phone:( _____ ) ______________
Alternate Contact: ____________________
Alternate Contact Phone: (_____ ) ____________
Address: _______________________________
______________________________________
Telephone: _____________________________
INSURANCE INFORMATION
Insurance Company: Group No.: ________________
Claim Office Address: _________________________
_________________________________________
Claim Office Phone Number: ____________________
Policy No.: _________________________________
Employer Name and Address: ___________________
__________________________________________
__________________________________________
MEDICAL INFORMATION
Special Medical Condition of Minor such as Diabetes, Allergic Reactions, Medications Currently Using:
_______________________________
_______________________________
_______________________________
Doctor’s Name: _______________________
Phone No.: (_____ ) __________________
Address: _____________________________
___________________________________
Date of Last Tetanus-Toxoid Booster:____________
Blood Type (if known) : _______________________
Will the Minor require any medication during any event?
Yes________ No ________
If yes-name of medication: ______________________
Dosage/frequency:__________________________
Minor administers? Yes: ____ No:_____
Needs Help: Adult Administers? Yes: ____ No:____
