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OREGON CITY EVANGELICAL CHURCHWAIVER AND RELEASE FROM LIABILITY
Effective June 2018 to June 2019

Today's Date: December 11, 2018

I (We) acknowledge that my child's participation in the Oregon City Evangelical Church youth program is voluntary and may require involvement in activities that require traveling or physical exertion. Such activities may include, but are not limited to: outings, athletic games, local excursions, and meetings. I (We) acknowledge that my child's participation in any Oregon City Evangelical Church youth activity presents risks that my child may suffer property damage, bodily injury, or death. Therefore, in consideration of my child's being allowed to participate in the Oregon City Evangelical Church youth program activities, I (We) agree to the following:

Oregon City Evangelical Church is not responsible for the loss or theft of personal belongings

I/we give permission to the Youth Pastor and staff of MS/SR High to drive my/our child in a church or personal vehicle, unaccompanied by another adult or student, when no alternative is available. This may be for varied reasons, such as, but not limited to: events, mentoring with staff member, emergencies etc. I/we understand that the leader will do everything in their power to protect the safety of my child. I/we understand that the leader will contact us to inform us of this necessity or any changes.

Misconduct may result in transportation home from any activity at parents' expense. A student dismissed for a disciplinary reason will not receive a refund of the activity fee.

I understand that my child's image may be photographed or filmed and used in video presentations and printed publications-either digital (online) or paper.

I hereby take the following action for my child, myself, my executors, administrators, heir, next of kin, successors and assigns: A) I waive, release, and discharge from any and all claims or liabilities for death or personal injury damages of any kind, which arise out of or relate to my child's participation in Oregon City Evangelical Church's youth activities, the following person, or entities: Oregon City Evangelical Church, it's Senior Pastor and Associate Pastors, Trustees, Church Council, employees, volunteers, representatives, subcontractors and agents of any of the above: B) I agree not to sue any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein except in the case of gross negligence on the part of Oregon City Evangelical, Oregon City Evangelical Staff or volunteers and: C) I indemnify and hold harmless the person or entities mentioned above from any claims made or liabilities assessed against them as a result of my student's actions. I hereby assume the risks of my child participating in all Oregon City Evangelical Church youth activities.

The undersigned (parent/guardian), the parent and natural guardian or legal guardian of the student hereby executes this document for and on behalf of the student named herein. I agree to indemnify and hold harmless the person or entities mentioned above for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the student in the execution of the Wavier and Release.

I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care facility to treat the student named herein for the purpose of attempting to treat or relieve any injury received by said student. I authorize any such medical provider to perform all procedures deemed medically advisable in attempting to treat or relieve any such injuries. I consent to the administration of anesthesia as deemed advisable. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk for and on behalf of myself and said student. I understand that attempts will be made to contact me in the most expeditious way possible. Permission is also granted to Oregon City Evangelical Church representative to provide the needed emergency treatment to the student prior to his admission to a medical facility.

I give my permission to the staff to administer Tylenol/Acetaminophen, Ibuprofen, Benadryl/Diphenhydramine, over the counter antacids as needed or other over the counter medicine as needed.

Please select who will be participating...
Minor
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First Student's Name

First Name*

Middle Name

Last Name*
First Student's Date of Birth*
First Student's Information

Medical Release Form Effective: June 2018 - June 2019


Fall of '18 School *

Fall of '18 Grade *

Student email address *

Student cell phone #
Text*
No
Yes

Medical insurance carrier *

Policy# *

Group#

Name of insured person

Insured person's place of employment

Name of primary care physician *

Phone *
Health History (Check & Give Approximate dates in the space below)
Frequent Ear Infections
Penicillin
Heart Defect/Disease
Insect Stings/Bites
Seizures
Tourettes Syndrome (specify in the space below)
Mumps
Diabetes
Asthma
ADD/ADHD
Chicken Pox
Bleeding Disorders
Mono
Downs Syndrome
Measles

Approximate dates
Allergies (dates not needed)
Hay Fever
Poison Ivy
Other
Drugs

Chronic/recurring illness/medical conditions including mental illness (depression, anxiety, etc.)

Food Allergies

Food Sensitivities

Current Medications (List both prescription, OTC & herbal)


Medication name:

Dosage

Reason for taking

Medication name:

Dosage

Reason for taking
Are all immunizations current? (MMR, tetanus-every ten years, hepatitis)*
No
Yes
Describe your students swimming ability:*

Any other information you feel the leaders should know in advance about your student

We ask that all students adhere to our rules of conduct on trips and events: respect for people and property, no violence, no alcohol/drugs/weapons/tobacco/fireworks permitted, students are not allowed to drive to events, modest and appropriate clothing, and participation with the group is expected. Failure to comply with these expectations could result in your student being sent home at parental expense. 

My child has permission to attend all church-sponsored youth activities as listed in calendars and/or Oregon City Evangelical Church bulletin, including but not limited to the following: cook-outs, boating, water-skiing, swimming, basketball, roller skating, games in the park, paintball, broomball, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides, bowling.

Note: If it is your desire to limit your child's participation in any event, please submit your wishes in writing to Oregon City Evangelical Church prior to that event.

First Student's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Additional Parent/Guardian Info

Home # *

Cell #
Text*
No
Yes

Address *

City *

State *

Zip *

Second Parent

Home #

Cell #
Text*
No
Yes

Work #

Parent email address
Alt. Emergency Contact

Alt. Emergency Contact *

Ph Home *

Ph Cell *
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*

Middle Name

Last Name*

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

Medical Release Form Effective: June 2018 - June 2019


Fall of '18 School *

Fall of '18 Grade *

Student email address *

Student cell phone #
Text*
No
Yes

Medical insurance carrier *

Policy# *

Group#

Name of insured person

Insured person's place of employment

Name of primary care physician *

Phone *
Health History (Check & Give Approximate dates in the space below)
Frequent Ear Infections
Penicillin
Heart Defect/Disease
Insect Stings/Bites
Seizures
Tourettes Syndrome (specify in the space below)
Mumps
Diabetes
Asthma
ADD/ADHD
Chicken Pox
Bleeding Disorders
Mono
Downs Syndrome
Measles

Approximate dates
Allergies (dates not needed)
Hay Fever
Poison Ivy
Other
Drugs

Chronic/recurring illness/medical conditions including mental illness (depression, anxiety, etc.)

Food Allergies

Food Sensitivities

Current Medications (List both prescription, OTC & herbal)


Medication name:

Dosage

Reason for taking

Medication name:

Dosage

Reason for taking
Are all immunizations current? (MMR, tetanus-every ten years, hepatitis)*
No
Yes
Describe your students swimming ability:*

Any other information you feel the leaders should know in advance about your student

We ask that all students adhere to our rules of conduct on trips and events: respect for people and property, no violence, no alcohol/drugs/weapons/tobacco/fireworks permitted, students are not allowed to drive to events, modest and appropriate clothing, and participation with the group is expected. Failure to comply with these expectations could result in your student being sent home at parental expense. 

My child has permission to attend all church-sponsored youth activities as listed in calendars and/or Oregon City Evangelical Church bulletin, including but not limited to the following: cook-outs, boating, water-skiing, swimming, basketball, roller skating, games in the park, paintball, broomball, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides, bowling.

Note: If it is your desire to limit your child's participation in any event, please submit your wishes in writing to Oregon City Evangelical Church prior to that event.

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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