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JR HIGH MINISTRY SUMMER CAMP 2021

at Twin Peaks Christian Conference Center 

July 19-23rd, 2021 

I represent that I am the parent or legal guardian of the minor participant identified below (hereafter “my child”). By signing this release, I hereby warrant that I have the legal right, without limitation, to enroll my child into the JUNIOR HIGH SUMMER CAMP 2021 at TWIN PEAKS CHRISTIAN CONFERENCE CENTER of Calvary Chapel Costa Mesa Junior High Ministry. By placing my signature below, I hereby grant my permission to allow my child to participate in the activity without restriction or limitation.

In consideration of Calvary Chapel Costa Mesa Inc.’s agreement to permit my child participate in the activity, the receipt and sufficiency of which consideration is hereby acknowledged, I, individually, and on behalf of my child and our respective heirs, successors, assigns and personal representatives, agree as follows:

(I) GENERAL LIABILITY RELEASE AND INDEMNIFICATION

I nonetheless authorize my child to participate in the activity and I agree that my child assumes any and all risks of injury or harm, of any kind, that may be sustained by my child while traveling to, from, or participating in the activity. To the fullest extent permitted by law, I fully release and discharge Calvary Chapel Costa Mesa Inc., its representatives, affiliates, subsidiaries, divisions, members, directors, officers, employees, agents, servants, volunteers, staff, speakers, teachers, or any of them (collectively referred to herein as “Calvary Chapel”), from all actions, suits, claims, causes of action, and demands for any injury or harm of any kind whatsoever which may arise from or out of my child’s travel to, from, or participation in the activity, however such injury or harm is caused, even if it is caused in whole or in part by action, inaction, or negligence of Calvary Chapel. This release is intended to discharge Calvary Chapel against any and all liability arising out of or connected in any way with my child’s travel to, from, or participation in the activity, even though that liability may arise out of the negligence or carelessness on the part of Calvary Chapel.

Should any claim be made or any lawsuit be filed against Calvary Chapel on account of any injury or damage to my child arising from any or related in any way related to my child’s travel to, from, or participation in the activity, I agree to defend, save, hold harmless, and to fully and completely indemnify Calvary Chapel for any and all amounts incurred, whether by settlement or judgment, including any amounts incurred by Calvary Chapel in defending against any such claim or judgment, including all attorney’s fees and costs incurred.

Moreover, should any claim be made or any lawsuit be filed against Calvary Chapel by any third party on account of the acts or conduct of my child arising from any or related in any way related to my child’s travel to, from, or participation in the activity. I further agree to defend, save, hold harmless, and to fully and completely indemnify Calvary Chapel from any and all amounts incurred, whether by settlement or judgment, as well as any amounts incurred by Calvary Chapel for defending against any such claim or judgment, including all attorney’s fees and costs incurred.

This general liability release and indemnity agreement shall apply to all known, unknown and/or unanticipated injuries and damages resulting from or during my child’s travel to, from, or participation in the activity from any cause whatsoever.

COVID- 19 Participation

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease (including transmission of viruses like COVID-19), bodily injury, death, emotional injury, personal injury, property damage, and financial damage. 

I understand that Calvary Chapel Costa Mesa is committed to providing a safe and healthy environment for all participants and visitors, and will continue to monitor and adhere to current CDC COVID-19 guidelines. I agree that I, or my child, as conference participants will adhere to CDC guidelines such as wearing masks during the event, maintaining social distances of 6 feet or more, washing/disinfecting hands often, and acknowledge that temperature checks may be taken at the door of the conference.

I agree to self-screen myself and/or my child for any COVID symptoms in the 14 days leading up to the conference, and will remain home if any symptoms are present such as: cough or shortness of breath, sore throat, fever of 100.4 degrees or higher, chills, muscle or body aches, new loss of taste or smell, unexplained fatigue, vomiting or nausea, diarrhea.

In consideration for the opportunity to participate in the activity described above (JR High Ministry Summer Camp 2021), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

(II) AUTHORIZATION AND CONSENT TO MEDICAL TREATMENT

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, 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 _________________________________________________________________________.

I authorize Calvary Chapel to arrange for or provide any necessary transportation for my child to the nearest medical facility for urgent or emergency medical treatment, if indicated, and I assume all responsibility for payment for such treatment. I acknowledge that my child has his or her own medical and dental insurance and I fully and unconditionally release and indemnify Calvary Chapel from all liability for any medical or dental treatment rendered to my child.

I hereby authorize and consent for my child to receive medical treatment, including any x-ray, examination, anesthetic, medical or surgical procedures which may be deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state or country in which such medical treatment occurs. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care to my child to which the aforementioned licensed medical professional or institution which, in the exercise of their best judgment, may deem advisable. I understand that every effort shall be made to contact me prior to rendering any medical treatment to my child, but that any of the above treatment will not be withheld if I cannot be reached. This authorization is given pursuant to the California Family Code section 6910, and similar provisions of the laws of the State or Country in which the medical or dental care is being sought.

I hereby authorize any hospital, medical facility, other medical provider who has provided treatment to my child to surrender physical custody of my child to Calvary Chapel upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California, and similar provisions of the laws of the State or Country in which the medical treatment has been provided.

These authorizations concerning medical treatment given to my child shall remain effective through the dates set forth above for the activity, unless sooner revoked in writing.

(III) VIDEO/PHOTO RELEASE

During the activity, photographs, audio recordings, and videos may be taken by Calvary Chapel and used for future publicity. I give permission for:

  • The use and storage of my child's name and image, by means of digital or film photography, video photography, audio recording or other documentation, with respect to the activity, namely Junior High Ministry Summer Camp 2021, of Calvary Chapel.
  • Use of any stored data including my child's name and image in electronic publications of Calvary Chapel.
  • Use of any stored data including my child's name and image in printed publications of Calvary Chapel.
  • Use of any stored data including my child’s name and image in any website created by or for Calvary Chapel for its sole benefit.

If I am signing this agreement on behalf of a minor child, I hereby warrant that I am the legal parent or guardian of the child and that I have the legal authority to sign this agreement on behalf of the child.

If a dispute over this agreement or any claim for damages arises, I agree to resolve the matter through a mutually acceptable alternative dispute resolution process. If I cannot agree with Calvary Chapel upon such a process, the dispute will be submitted to a three-member arbitration panel of the American Arbitration Association for final resolution.

No oral representatives, statements, or inducements have been made by or between the parties to this Agreement with respect to the subject matter of this Agreement apart from the matters set forth within this Agreement.

In signing this Agreement, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it affects my legal rights and those of my child, that it is a binding Agreement, and that I have signed it knowingly and voluntarily.

First Participant's Name

First Name*

Last Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

First Participant's Signature*
Second Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Third Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Fourth Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Fifth Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Sixth Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Seventh Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Eighth Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Ninth Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Tenth Participant's Name

First Name*

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

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Parent or Guardian's Information

Street Address

City

State / Zip

School Attending

Parent Email Address

HEALTH HISTORY 


Allergies
1. To your knowledge, has your child been exposed to any communicable diseases within the past 21 days?*
No
Yes

If yes, which ones:
2. Does your child have Asthma?*
No
Yes
If yes, did they pack an inhaler?*
No
Yes

3. Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity? If yes, please explain

4. Date (or year) of child's last Tetanus shot

MEDICATION INFORMATION 


Medication

Dosage

I give my informed consent to allow Calvary Chapel and any First Aid personnel assigned by Calvary Chapel, to provide basic First Aid and comfort measures to my child through standardized treatment procedures which includes the use of over-the-counter medications. I authorize Calvary Chapel to provide my child with the following generic, over-the- counter medications as directed by the labels provided by the manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti-nausea/diarrhea, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement uids, analgesic balms and gels, with the exception of

PARENT / EMERGENCY CONTACT 


Name *

Phone

Name

Phone

Parent's Employer

Address

Insurance Company

Policy Number

Child's Regular Physician

Policy Holder

BY SIGNING BELOW, I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. 

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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