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Riverside Presbyterian Church, Youth Medical Release

RELEASE AND HOLD HARMLESS AGREEMENT

By my signature, I,the parent or guardian of ("Minor") grant my permission for him/her to participate fully in any activities or trips sponsored by Riverside Presbyterian Church. I understand that my signature carries with it the following:

  • An authorization of any of the adult leaders to obtain necessary medical attention and/or treatment for my son/daughter.
  • I knowingly release, absolve, indemnify and hold harmless Riverside Presbyterian Church from all claims that might result from any injury or death of my dependent/child. This agreement pertains to all programs and activities, including those where transportation is provided.
  • I knowingly release, absolve, indemnify and hold harmless all drivers for Riverside Presbyterian Church from all claims that might result from any injury or death of any minor.
  • Should medical help be needed, I agree to pay either directly or through my own personal health and accident insurance policy all medical or hospital costs occurring to my own child/dependent.

Date: July 18, 2018

Please select who is participating in the RPC Youth program or summer trip
AdultMinor
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First Participant's Name

First Name*

Last Name*

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

Allergies (Food/Medications)

Reaction

Allergies (Food/Medications)

Reaction

Medications


Medications

Dosage (mg)

How Often

Medications

Dosage (mg)

How Often

Medications

Dosage (mg)

How Often

Family Doctor


Name: *

Office Phone: *

School Information


School *

Grade: *

School Activities you are involved in

Other activities outside of school

Hobbies + Interests

Favorite Candy

Insurance Information


Insurance Company *

Phone *

Address

Insurance Address Line 2

Policy Under the Name of

Policy # *

Group # *

IN CASE OF EMERGENCY


#1 EMERGENCY CONTACT


Name: *

Relationship: *

Cell Phone: *

Home Phone:

#2 EMERGENCY CONTACT


Name:

Relationship:

Cell Phone:

Home Phone:
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*

Relationship*

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