Medical Release and Event Permission:

In the event of a medical emergency, procedures must be clearly outlined and understood by both parents and leaders. If you list the names of all your children on this form, it will not be necessary to complete a separate form for each child.

Child/Childrens Name(s) *

Child/Childrens Name(s)

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

Cell Phone

(###)

###

####

Home Phone *

Home Phone

(###)

###

####

Parent Email Address *

Parent/Gaurdian's Name *

Parent/Gaurdian's Name

In the event of illness or medical emergency, the leader will attempt to contact parents for instructions. If the leader is unable to contact you, the leader will have the authority to have the child treated by any licensed physician and/or surgeon who may perform such procedures or administer such medications as the emergency requires for the relief of pain or to preserve life and health. In non-medical emergencies, the leader will take what action seems to be normal and appropriate.

First Name

Last Name

Parent/ Gaurdian's Phone *

Parent/ Gaurdian's Phone

(###)

###

####

Parent/ Gaurdian's Name 2

First Name

Last Name

Parent/ Gaurdian's Phone 2

(###)

###

####

Family Doctor *

Doctor's Phone *

Doctor's Phone

(###)

###

####

Health Insurance Company

Policy Number

Would You Like To Use Parent Information as Emergency Contact? *

Yes

If No: Please enter emergenct contact information here:

First Name

Last Name

Emergency Contact Phone

(###)

###

####

2. Does your child have any allergies or health problems of which we should be alerted? *

By signing at the bottom of this page, I hereby agree that I have read the above policy and am in agreement with its provisions in total. I also assume financial responsibility for use of an ambulance to transport my child to the nearest health care facility should such a need arise. *

I Agree

EVENT PERMISSION: I hereby give my permission for my child/children (Name mentioned above) to go with Calvary Temple to Off-Site events in 2019-2020. By signing below, the parent/guardian gives consent to the said child to participate in a church sponsored activity. The undersigned agrees to hold harmless (which means to not assign blame or legal responsibility) Calvary Temple International Assembly, its officials and those workers assisting in the activity from any and all harm that may be sustained as a result of or during the activity, including transportation to and from the activity. Parent further agrees to resolve any dispute arising from any harm where the matter is, by mutual consent, deemed not covered by this consent or over the consent itself, by submission to binding arbitration. *

Please Print Full Name Below- This will be your Digital Signature