Journey Students -  Medical/Liability Release Form  

2017-2018

Fill out the form below, and submit as your approval for your students's participation in events for the Ministry year of June 1, 2017 thru May 31, 2018.

For questions, contact Lisa at office@journeycc.net or Tony@journeycc.net   ---   209-833-8470.

PERSONAL INFORMATION:
Participant Full Name: *
First Name
Middle
Last Name
Today's Date: *
Primary Phone: *
Birth Date: *
Current Grade:*
Mailing Address: *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
PARENTAL/GUARDIAN CONSENT: As the parent or legal guardian of the above named minor, I give my permission for him or her to participate in activities, events, and programs of Journey Christian Church during the year June 1, 2017, through May 31, 2018. I understand the inherent risks that are involved in these activities and hereby release JCC, its staff, employees and volunteers from responsibility and liability for any injury or illness sustained during these activities, events, and programs. Further, I do authorize the minister, adult leader, or sponsor of the activity, event, or program, or any JCC staff member, in the event I cannot be reached by phone, to give consent to a physician and or hospital for emergency medical or surgical treatment. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment. Further, I authorize Journey Christian Church to use photographs and video footage of the participant for promotional materials.
Full Name of Parent/Guardian: *
First Name
Middle
Last Name
Re-enter Full Name of Parent/Guardian: *
First Name
Middle
Last Name
Date of Signature:*
MEDICAL INFORMATION:
Medical Insurance Company:*
Policy Number:*
Group Number: *
Primary Insured Name: *
First Name
Middle
Last Name
Physician Name: *
Physician Phone: *
Emergency Contact: *
First Name
Middle
Last Name
Emergency Phone: *
2nd Emergency Contact:
First Name
Middle
Last Name
2nd Emergency Phone:
MEDICAL HISTORY:
Allergies (list foods, drugs, environment with description of reactions):
Current Medicines (List drug, dosage, when taken, prescription or over-the-counter):
Special Considerations and Info: