High School and Junior High Medical Release Form Last Name:
Medical Release and Consent Form for Church Activities and Trips
I, the undersigned parent(s) or legal guardian(s), hereby consent to my child, , who is years of age, participating in all activities connected with Shore Fellowship Church for 2008 calendar year (1/1/08-12/31/08). I understand that the transportation used will consist of Church van(s) and /or church bus. I understand that this activity will include but not be limited to the following: basketball, volleyball, paintball, swimming, laser tag, skiing, football, Frisbee, tennis, ping-pong, camp events, and roller/ice skating. We will leave and return to the church as posted on the flyer handed out (please call the church for updates or changes to this time). I certify that my child is able to participate in any and all of these activities. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them below. If I cannot be reached within a reasonable period of time, as determined by church official(s), I hereby authorize the church or adult sponsor, to make emergency medical decisions for my child. If there are any activities that I do not want my child to be involved in, I have listed them below.
I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do, for myself and for my child, heirs and assigns, hereby irrevocably and unconditionally release, acquit and forever discharge Shore Fellowship Church and its agents, employees, and volunteers from any liability, actions, causes of actions, claims, expenses, obligations and damages of any nature whatsoever, which I now have or which may arise in the future, in connection with my child’s participation in the described activity or in any other associated activities including, but not limited to, any injury to my child or property, even injury resulting in death.
I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of New Jersey and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto.
I further state that I HAVE CAREFULLY READ AND UNDERSTAND THE FOREGOING RELEASE AND KNOW THE CONTENTS HEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. I understand that this is a legally binding agreement.
Medical condition(s) to be aware of (allergies, asthma, seizures etc.):
Medical Insurance Company: Policy#
Date of Last Tetanus Shot:
Instructions and medications:
I do NOT wish my child to participate in the following:
Signature of Parent or Guardian / Date Signature of Parent or Guardian / Date
Telephone Numbers where I may be reached (please include area code)
Phone # Contact Cell # contact
Phone # Contact Cell # contact