Grace Students Medical Release Form

Today's Date*

Student's Name*

Student's Birthday*

Phone*( ) -

Parent/Guardian Information

Parent/Guardian Name*

Primary Phone Number*( ) -

Secondary Phone Number*( ) -

Parent/Guardian E-mail*

Emergency Contact and Health Insurance Information

Insurance Carrier*

Name of Policy Holder*

Group Number*

Policy Number*

Family Doctor

Doctors Phone Number

Emergency Contact Name*

Relationship*

Emergency Contact Phone Number*( ) -

Parental/Guardian Permission for Medical Treatment

In the event of circumstances that my child is in need of medical care, I authorize the Grace Church representatives to consent to any necessary X-ray, examinations, medical or surgical diagnosis, treatment, medication, or hospital care in accordance with standard medical practice by licensed medical personnel. I release and agree to hold Grace Church, its employees and volunteers, harmless from any claims due to illness or injury suffered by my child in the course of receiving such medical responsibility and consequences that may arise as a result of this treatment. I grant permission to the employees and agents of Grace Church to give my child non-prescription drugs in the event circumstances reasonably demonstrate that my child is in need of such non-prescription drugs.

Release of Liability

By signing and submitting this Waiver form, I expressly warrant that the child listed above is capable of withstanding physical and mental demands of the Grace Church Youth Group Activities. I also expressly assume all risks of the child when participating in the activities, whether such risks are known or unknown to me at this time. I further release Grace Church and its staff, leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against Grace Church or its staff, leaders, employees, volunteers, or agents from any and all clim rising from my participation in its activities and programs, or as a result of injury or illness of my child during such activity.

Electronic Signature*

Please leave this field blank.