Medical Release Permission Form and Release of Liability

Medical Release Permission Form and Release of Liability - GCK

In consideration for being accepted by Great Commission Church (GCC) to participate in the following event listed below, I do hereby release and forever discharge and agree to hold harmless GCC and the directors thereof 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 participant that occur while said person is participating in said trip and activities. The undersigned further agrees to hold harmless and indemnify said church, its directors, employees and agents for liability sustained by said participant, including expenses incurred attendant thereto. The undersigned further consents to administration of first aid and/or doctor's care, or any other form of medical treatment necessitated by illness or injury that may require the same.

Event

If you agree with the above statement type your full name below:

Parent or Guardians Full Name

CHILD INFO

List all Childrens full names and Date of Birth who are going to the event listed above

INSURANCE & MEDICAL INFO

Insurance Company Name and Policy#

ID# and/or Group#

Insurance Company Phone Number

Child's known allergies (environmental AND medications, please):

Child's known medical conditions/issues that we need to be aware of:

Are there any other special circumstances or physical limitations that we need to be aware of?

PARENT INFO:

First Name

Email Address

Last Name

Mobile Number

EMERGENCY CONTACT INFO

In Case of Emergency, Notify:

Relationship

Best Contact #

If parent or emergency contact can't be reached:

In the event I am unable to be reached, I also grant the GCC staff & chaperones the authority to make medical decisions for my child while he or she is in their care.

Please list the following: Childs Social Security numbers / Names and numbers for: Family Docter / Family Dentist

By signing below, as the parent/legal guardian of the child, I am registering for the event listed above. I hereby give Great Commission Church Staff and/or chaperones permission to secure medical treatment for my child.

Signature of Parent or Guardian