Loading...

Grace Medical Release and Liability Waiver. 
If any of this information should change while your child is participating in outside activities at Grace, please notify the church office of these changes immediately.

In the event I cannot be reached in an emergency, I hereby knowingly and voluntarily give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary.

Even with the best planning and precautions, unforeseen events or accidents can occur. By signing this form, the below indicated parent, guardian, or legal representative of the child or children named herein signifies that he or she fully understands the church activity participated in and knowingly and voluntarily accepts all risks and hazards inherent in such activity.

Further, the below indicated parent, guardian, or legal representative of the child or children named herein agrees to hold harmless Grace Church, its employees and/or volunteer assistants from any and all liability for damages, losses, or injuries to the person or property of any child or children named herein caused by acts or omissions amounting to simple negligence and to refrain from instituting any cause of action against any employee and/or volunteer of Grace Church to recover losses, whether medical or otherwise arising from acts or omissions.

Please select who will be participating...
Minor
Continue
First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
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*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Insurance
Insurance Carrier*
Insurance Policy Number*
Health History Information
Allergy information
Drugs
Food
Insect Stings
Other Allergies
Other Health Issues:
Asthma/Respiratory
Behavioral
Chronic Headaches
Chronic Illness
Diabetes
Heart/Cardiac
If you marked any of the above, please give details (i.e. include normal treatment of allergic reactions, etc.):___________________________________

Name and dosage of any medication(s) (including prescription, over-the-counter, herbal treatment) that must be taken while at camp. Note: **ALL medications must be given to Grace Student Ministry Staff to be administered during any Grace Event.**

List any restrictions here (i.e. unable to swim, unable to walk long distances, etc.):
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*
Middle Name
Last Name*
Relationship*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!