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GracePoint Church

Kids & Youth Ministries

Medical & Liability Form


This information could be important in the event of an emergency. Please be as accurate as possible.

WAIVER OF LIABILITY

I do fully and expressly release, indemnify, and hold harmless GracePoint Church, 801 South Lower Sacramento Road, Lodi, California, its Board, Members, staff, employees, and their assigns from any and all liability for any harm, including, but not limited to, any accident(s), injury(ies), or death, incurred by my child as a result of his/her participation in any event, including, but not limited to, any athletic, recreational, social, or other activity, sponsored or attended by GracePoint Church youth ministries.

Today's Date: June 8, 2023

First Participant Name

First Name*

Middle Name

Last Name*
First Participant Date of Birth*
First Participant Information

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
First Participant Signature*
Second Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Third Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Fourth Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Fifth Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Sixth Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Seventh Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Eighth Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Ninth Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Tenth Participant Name

First Name*

Middle Name

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

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
Participant 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

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Grade: (if you are an adult, write Adult) *

Parent's Information


Parents/Guardian(s) Name *

Parents Email *

Parent's Cell Phone: *

Parent's Home Phone:

PARENT(S)/GUARDIAN(S): You must check option 1 or option 2 to indicate the desired action in the event of an accident or emergency. 

1. In the event of an accident or another emergency, when a parent/guardian is unavailable, I hereby authorize a representative of GracePoint Church to make such arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is unavailable at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
I choose Option 1

If you choose Option 1 - THE UNDERSIGNED HEREBY AGREES TO BEAR ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. 


Physician's Name:

Telephone No.:

Health Insurance Provider:

Group ID No.:
2. I do not choose the above statement and desire that the following action be taken:
I choose Option 2

Actions to be taken

Health History


Please list any allergies (health/food):

Please list any health conditions we should be aware of:

Date of last tetanus shot:

Any other information we need to know:
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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