Outdoor activity waiver in digital

Minor Participation Authorization, Media Release, and Consent to Emergency Medical Treatment Form

I, the undersigned, certify that I am the parent or legal guardian of the “minor child”.

I hereby give my consent to have my minor child participate in Student activities at First Assembly of God from July 28, 2016 through July 28, 2017.

I authorize First Assembly of God to use my child’s likeness in photographs or video in any and all publications and media. I will make no monetary or other claims against First Assembly of God for the use of such photos or videos.

I recognize that there are risks involved in participating in Student activities and hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in this activity.

To the fullest extent permitted by law, I release First Assembly of God, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless First Assembly of God, its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activity.

Further, being the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. Any insurance policy of the church or organization sponsoring this event will be used as the secondary coverage.

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Witness: * Please enter your answer here.

Date of Today: *

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Please complete the Emergency Contact and Medical Information Section below

Emergency Contact and Medical Information

Parent/Legal Guardian Name: Please enter your name.

Home Phone: Please enter your phone number.

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2nd Parent/Legal Guardian Name: Please enter your name.

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Medical Information

Home Address: *

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Email: * Please enter your email.

Insurance Company Please enter your answer here.

Name on Policy: Please enter your answer here.

Policy Number: Please enter your answer here.

Group Number: Please enter your answer here.

Allergies: Please enter your answer here.

Other Health Notes: Please enter your answer here.

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