Loading...

Medical Release Waiver for Kansas City District Middle School Camp

I am the Parent/legal guardian of the above named minor of whom I have full custody and control, who will be attending Middle School Camp at Sunstream Retreat Center. I consent to the necessary medical and/or dental treatment, including the decision for hospitalization, and if necessary, surgery, hereby authorizing the Kansas City District Church of the Nazarene, and its agents, to secure the necessary medical or dental treatment for said minor and to receive any necessary assistance

In consideration of permission granted to child by Kansas City District Church of the Nazarene NYI, its agents, executors, administrator, or assigned employee from any grievance I may have, or claim to have against the Kansas City District Church of the Nazarene NYI, its successors or assigned employee, for all personal injuries, known or unknown and injuries to property, real or personal, cause by, or arising out of, the above described event, Middle School Camp, to be held at Sunstream Retreat Center. 

I, the undersigned, have read this release and understand its terms, I execute it voluntarily and with full knowledge of its significance. I have executed this release as a parent or guardian of the above child as stated above. 

 

First Participant's Name

First Name*

Middle Name

Last Name*

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Third Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Fourth Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Fifth Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Sixth Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Seventh Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Eighth Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Ninth Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
Tenth Participant's Name

First Name*

Middle Name

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

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Information

Current Medications

Physical Impairments

Allergies

Any other medical information that we need to be aware of
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!