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Form – Student Ministry Release Form
Katelyn Bissett
2021-03-19T10:52:09-04:00
Grace Students Liability & Medical Release Form
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GFC Waiver and Release
We (I) agree to hold harmless Grace Fellowship Church 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 the child participant that occur while said child is participating in this event. Furthermore, we (I) [and on behalf of our (my) child participant] hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved wherein. We are (I am) the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in this event, and hereby give permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. GUIDELINES AND DISCIPLINARY ACTION: Furthermore, we (I) and said participant fully understand and agree to comply with the following guidelines and support the mentioned appropriate disciplinary action: 1. Physical restraint against another’s will, including verbal threats to bring harm, constitutes assault/battery and will result in dismissal of event and possible lawful action. 2. Possession and/or use of alcohol, tobacco, weapons, or illegal drugs will result in confiscation, dismissal of event, and possible lawful action. 3. Inappropriate sexual conduct will result in immediate consultation, parental awareness, and possible dismissal of event. Should it be necessary for the participant to return home due to disciplinary action, medical reasons, or otherwise, we (I) assume all transportation costs. Photograph and Video Release: I hereby grant to Grace Fellowship Church the rights to use my name, image, and likeness, sound of my voice or performance as recorded photographically, on audio, video tape or other recordable media now known or later developed, without payment or any other consideration. Applies to but not limited to printed material, internal and external use, website, fundraising and social media. These may be electronically displayed via the internet or in a public setting.
Check Below
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By checking this box, I have read and agree to the terms above
Sign
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First
Last
Date
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COMPLETE THE FOLLOWING:
Parent Name
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First
Last
Parent Email
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Parent Phone
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Household Address
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Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Participant's Name
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First
Last
Participant's Birthdate
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Gender
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Male
Female
Current Grade
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School Attending
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Are you filling out this release for more than one student?
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Yes
No
If yes, they must be within the same household
Participant 2 Name
First
Last
Participant 2 Birthdate
Gender
Male
Female
Current Grade
School Attending
Participant 3 Name
First
Last
Participant 3 Birthdate
Gender
Male
Female
Current Grade
School Attending
EMERGENCY CONTACT
Emergency Contact Name
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First
Last
Relationship
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Phone
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MEDICAL INFORMATION
Insurance Company
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Policy #
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Insurance Phone #
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List any known medical conditions or medication taken:
*IF MORE THAN ONE CHILD, PLEASE SPECIFY
Please attach a front and back copy (photo) of your insurance card(s)
*
Click or drag files to this area to upload.
You can upload up to 6 files.
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