Permission Form

AMPLIFY Senior High Retreat 2008

PLEASE staple a photocopy of BOTH SIDES of your medical insurance card to this form. PARENT PERMISSION: I hereby grant permission for my child to fully participate in the Sr. High Retreat activity sponsored by First Christian Church (further known as “the church”) and held at Elkhorn Valley Christian Service Camp (further known as “camp”). While I understand that the adult representatives of the church and/or camp will take all reasonable steps to provide care and safety for my child throughout the duration of the program, I am aware that the church and camp, their employees, and agents cannot assume responsibility for the injury, damage, or harm that might result during the course of the program. In permitting my child to participate, I agree that such responsibility will remain with me, as parent or guardian of my child. Should any claim be asserted by any person as a result of the acts of my child while participating in this program, or while traveling to or from any such activities, or should my child assert any claim against the church and/or camp or any employees or agents of the church and/or camp, I agree to indemnify and hold the church and/or camp harmless from any such claim, including (but not limited to) attorney’s fees and costs incurred in defense thereof. EMERGENCY AUTHORIZATION: I hereby give permission to the adult representatives of the church to authorize medical treatment for my child in the event of an emergency. I give permission to the medical personnel attending to the treatment of my child to order x-rays, routine tests and treatment. In the event I cannot be reached in an emergency, I hereby give permission to the attending physician to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child named on this form. Signature or parent/guardian ____________________________________________________ Date ________________ Witness _____________________________________________________________________ Date ________________ EMERGENCY ADMISSION INFORMATION: Parent/Guardian – these are questions that will be asked of your child in the event that there is a need to take him/her to the emergency room of a hospital. Having this information available will expedite the admission process and the treatment of injuries or illness.

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Attendees Information

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Last Name __________________________ First Name _________________________ MI ____ Sex ____ Home Address _______________________________________________ Graduation Year ____________ City ________________________________________ State ___________ Zip +4 ____________________ Home Phone (_______) _____________________ Parent’s Work Phone (_______) __________________ Emergency Phone (_______) ______________________ Relationship _____________________________ County of Residence __________________ Birthdate ______________ Age _____ SSN# ______________ ---------------------------------------

Insurance Company Information ---------------------------------------

Complete Name of Insurance Company ______________________________________________________ Policy Holder Name _____________________________________________________________________ Group # __________________________________ Group Name _________________________________ Address of Insurance Company ____________________________________________________________ City ______________________________________ State ____________ Zip +4 _____________________

Where is the policy holder employed? _______________________________________________________ Employer’s Address _____________________________________________________________________ City ______________________________________ State ____________ Zip +4 _____________________ Employer’s Phone # (______)____________ If self-employed, give occupation _______________________ ---------------------------------------

Parent/Guardian Information ---------------------------------------

Father’s Name ____________________________________________________ Birthdate _____________ Mother’s Name ___________________________________________________ Birthdate ______________ --------------------------------------- Health History Form --------------------------------------Health History (Mark with an “X” and give approximate dates) __ Ear, Nose and Throat disorder __ Heart defect/disease __ Convulsions __ Diabetes __ Bleeding, clotting disorders __ Hypertension __ Asthma

Diseases __ Chicken pox __ Measles __ German Measles __ Mumps __ Hepatitis __ Mononucleosis

Allergies __ Ivy poisonings, etc. __ Insect stings __ Penicillin __ Other drugs __ Foods __ Grass, weeds, pollen

Operations or serious injuries (dates) ________________________________________________________ Disability or chronic recurring illness _________________________________________________________ Dietary modifications _____________________________________________________________________ Current medications (send with instructions) __________________________________________________ Other diseases or details of above __________________________________________________________ Suggestions or health related information for medical personnel or adult volunteers and staff ______________________________________________________________________________________ ______________________________________________________________________________________ When was the date of the student’s last Tetanus Shot? ____________________ Swimming restrictions

__ Yes

__ No

If yes, please explain on the back of this paper.

Name of dentist/orthodontist __________________________________ Phone (_____) _______________ Name of family physician _____________________________________ Phone (_____) _______________ Date of last physical examination ______________________________ This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. I hereby authorize and assign permission for the First Christian Church Student Ministries staff and volunteers to photograph my child. These photographs may be used in follow-up publications on the web and print for the purposes of marketing and publicity for future conferences. Signature of Parent/Guardian __________________________________________ Date _______________