Medical Release

Parental Consent, Waiver, & Medical Release Form Student Extreme Ministries- Hazel Dell Christian church Name: _____________________________ Age: ______ Birth date: ____________ Address:__________________________________ Phone: (___)_______________ City: _______________________________ State: _______ Zip code: ___________ School: ______________________________ Grade in or just completed: _______ Parent (s) names: _____________________________________________________ Parent(s) work numbers: _______________________________________________ We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services given to the child on this release form. Should it be necessary for my (our) child to return home due to medical reasons or otherwise (ie- discipline problems, family concerns, or emergencies), the undersigned shall assume all transportation costs. Furthermore, I understand that in the event my child becomes unruly or disobedient, authority personnel at Hazel Dell Christian Church reserve the right to discipline and I could be asked to come and get my child from an event. I also agree to hold the above-named organization harmless of and from any and all liability of whatever nature, which may arise out of or result from participation in events, activities, or sports sponsored by the Hazel Dell Christian Church Student Ministries. The undersigned does also hereby give permission for my (our) child to ride in any vehicle designated by the adult (21 or older) in whose care the minor has been entrusted while attending and participating in activities sponsored by Hazel Dell Christian Church Student Ministries. I hereby give permission for my (our)child, __________________________ to attend and participate in activities sponsored by Hazel Dell Christian Church Student Ministries.

Participant signature

Printed name

Parent signature

(if child is under 18)

Printed name

Legal guardian

(if child is under 18)

Printed name

Date

Date

Date

We take several pictures on trips and events that we use for publications & our website. Please check this box if we can use a picture with your teen in it. ___ Please fill in medical information on the reverse side of this sheet. Thank you.

Medical Information Health Insurance Company: _______________________________________________ Address/City/Zip code of company: _______________________________________________ _______________________________________________ Phone number of company (____)_________________ Policy number/Group ID: _______________________ Emergency contact number(s): _____________________________________________ Relationship to participant: _______________________________________________ Please list any allergies, special medical problems, or prescription medication your child has or takes (along with the reason) below. Thank you. Allergies: ______________________________________________________________________ ______________________________________________________________________ Special Medical Problems: ______________________________________________________________________ ______________________________________________________________________ Prescription Medications/reason: ______________________________________________________________________ ______________________________________________________________________ **Please give all medications to designated adult leader. Thank you! *Note*- Your child will not be allowed to participate in an event or activity unless both sides of this form are completed in their entirety and the form is notarized. To be completed by a Notary Public: County of___________________________ State of_____________________________ Country of_____________________________ On this day of ___________________ in the year 20___, before me, the undersigned notary public, personally appeared the above named individuals for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal ____________________________ (Notary Public Signature) ____________________________ (Commission Expiration Date)