Print copy, fill out in entirety, then turn the release form into the Pastor Nick.

Full Liability, Discipline, and Medical Release Form

STUDENT NAME:  _____________________________________________________

ADDRESS:  ____________________________________________________________

CITY:  _____________________  STATE:  ________________  ZIP:  _____________

PHONE:  __________________  BIRTHDATE:  ______________  GRADE:  ______

NAME OF PARENTS/GUARDIANS:  ______________________________________

NAME OF PHYSICIAN:  __________________  PHYSICIAN PHONE:  _________

HEALTH INSURANCE PROVIDER:  ______________________________________

POLICY #:  _____________________________________________________________

LIST OF KNOW ALLERGIES AND SPECIAL NEEDS:  ______________________

________________________________________________________________________

LIST OF CURRENT MEDICATIONS:  _____________________________________

________________________________________________________________________

I, ________________________, the legal parent/guardian of the student listed on this release form, attest that he/she has my full approval to attend services and events with the First Christian Church Ministry staff and volunteers.  I understand that the student listed on this release form is expected to abide by the rules of the church and staff and will be directly responsible to said church and staff.  I understand due to misconduct or disobedience my child may be required to leave services or event at First Christian Church.  In such an instance I will assume full responsibility for returning the student to his/her home.

Further, I do release First Christian Church and the their staff and volunteers from any and every claim arising, or which may be asserted by me or by any member of my family by reason of participating in an activities, events, or services associated with First Christian Church and/or the staff and volunteers.  I also authorize the ministry/staff/

sponsor of said events, services, or activities, in the event I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while on this trip.  It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment, including travel expenses and medical fees. 

Further, I do certify that said student is covered by adequate medical and accident insurance.  My consent and signature are given below.  I have read and agree to the information give in this entire form. 

________________________________________________________________________________________________

SIGNATURE OF PARENT/LEGAL GUARDIAN:  ___________________________

PRINTED NAME:  ___________________  DATE:  ___________________________