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2018 Prescott Christian Church Youth Ministry

Permission & Medical Release and Waiver of Liability and Indemnity Agreement

Permission & Medical Release / Release and Waiver of Liability and Indemnity Agreement

I, the undersigned, being a parent/legal guardian of above named participant, give my permission for the above named participant (hereinafter referred to as “Participant”) to participate in various programs, events, or activates (hereinafter collectively referred to as “Activates”) operated or sponsored by Prescott Christian Church (hereinafter referred to as “PCC”).

I understand that the above the participant is responsible for knowing the rules and regulations, of activities made by PCC staff and sponsors.

 I hereby authorize an adult leader of PCC to take the participant to a medical doctor for examination and treatment of any accident or illness that may arise while on a PCC sponsored activity. I understand that in the event of a medical emergency, every effort will be made to contact the parent/guardian listed. In the event I cannot be reached, I hereby authorize any physician, nurse, medical authority and/or hospital to administer proper treatment to the participant.

In consideration of being permitted to participate in PCC operated or sponsored activities, I, the undersigned, on behave of the participant, hereby releases, waives, discharges and covenants not to sue PCC, it’s officers, directors, agents, employees, and volunteers, from liability for any and all claims including the negligence of PCC, it’s officers, directors, agents, employees, and volunteers resulting in illness, bodily damage, personal injury (including death) and property loss arising from participation in PCC operated or sponsored activates.

I, the undersigned, on behave of the participant, hereby agrees to indemnify and save and hold harmless PCC, it’s officers, directors, agents, employees, and volunteers, from any loss, liability, damage, or cost that may incur due to the participant’s participation in PCC operated or sponsored activates.

Photo Waiver

The undersigned, on behalf of above named participant grants Prescott Christian Church to use the above named participant’s photograph or likeness in any promotional material or future publications to represent Prescott Christian Church. The undersigned acknowledges and agrees the undersigned or the above participant will not be entitled to compensation for such use.

I, the undersigned, further expressly agrees that this authorization and agreement is intended to be as broad and inclusive as is permitted by the law of the state of Arizona and that if any portion thereof is held invalid, it is agrees that the balance shall notwithstanding, continue in full legal force and effect.

I, the undersigned, on behalf of the participant, have read and voluntarily signed this authorization and agreement, and further agrees that no oral representations, statement or inducement apart from the forgoing written agreement has been made.

I, the undersigned, on behalf of the participant, agree to notify PCC leadership of any changes to the information provided on the release/agreement.

This authorization shall remain effective through unless sooner revoked in writing and delivered to said agents.

Dated: June 24, 2018

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
First Participant's Signature*
Second Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Third Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Fourth Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Fifth Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Sixth Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Seventh Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Eighth Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Ninth Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Tenth Participant's Name

First Name*

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

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parents (Legal Guardians) Contact Information

Mother:

Cell #:

Alt #:

E-mail:

Father:

Cell #:

Alt #:

E-mail:

Alternate Contact:

Relationship:

Cell #:

Alt #:
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Grade: *

Student's Cell (Not parents. Please enter N/A if they do not have one or do not want to input): *

Student's E-mail (Not parents. Please enter N/A if they do not have one or do not want to input): *
Student lives with:*

Other

List anyone legally restricted from seeing student:
Swimming Ability:*

Medical Information


IMMUNIZATIONS: Date of Tetanus shot/booster:

Allergic reactions: (If none please enter "NONE") *
Any health issues or medications:*
No
Yes

List all medication participant is taking: (Include: Type, Dosage, Frequency, Purpose - If none, please enter "NONE") *

List all medical and health issues: (If none, please enter "NONE")

Permission is also hereby given for PCC staff or sponsors to administer the following generic over-the-counter medications as directed by the labels provided by the manufacturer for the participant: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels, with the exception of: (IF none, please enter "NONE")
Medical insurance:*
No
Yes

Medical Insurance Company:

Policy #:
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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