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Liability & Medical Release

Project Timothy East

Today's Date: April 20, 2024

I, as parent/legal guardian of the minor(s), understand that my child will be attending Project Timothy at The Barn Vineyard Church in Landenberg PA. I understand that during this time he/she will be accompanied by volunteers from this and other Vineyards in our region under the direction of staff and volunteers from the East Region of the Vineyard and The Barn Vineyard Church.

I hereby release The Barn Vineyard Church as well as any other Vineyard church who provides volunteer staff, their staff and volunteers, and any sponsors of the event, from responsibility and liability for any loss, injury, or illness that my child may sustain during any activity. In the event of an emergency, I understand that every reasonable effort to contact me will be made. In the event that I am unable to be contacted, I hereby authorize an adult leader, as agent for me, to consent to any medical, dental, or surgical diagnosis; X-ray examination; and/or hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state or province where the services are rendered, either at the doctor's office or in any hospital.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

MEDICAL INFORMATION


ALLERGIES

MEDICATIONS

DOCTOR'S NAME & PHONE *

OTHER INFORMATION

INSURANCE COMPANY *

POLICY NUMBER *

SUBSCRIBER NAME *

GROUP NAME OR NUMBER *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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