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    Medical Waiver 2014-2015

    Uploaded by

    api-73377093
    This form collects medical, contact, and insurance information for students attending events at The Grace Place and Salem Baptist Church for the 2014-2015 school year. It requests details about students' medical conditions, medications, immunizations, and any special instructions if medical attention is needed. Parents must provide their contact and insurance information. By signing, parents give permission for their children to participate in all activities and consent to medical treatment if needed. They also release the church from liability and responsibility for medical costs. The information will be kept confidential.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Waiver 2014-2015

    Uploaded by

    api-73377093
    47 views4 pages
    This form collects medical, contact, and insurance information for students attending events at The Grace Place and Salem Baptist Church for the 2014-2015 school year. It requests details about students' medical conditions, medications, immunizations, and any special instructions if medical attention is needed. Parents must provide their contact and insurance information. By signing, parents give permission for their children to participate in all activities and consent to medical treatment if needed. They also release the church from liability and responsibility for medical costs. The information will be kept confidential.

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    medical waiver 2014-2015

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    This form collects medical, contact, and insurance information for students attending events at The Grace Place and Salem Baptist Church for the 2014-2015 school year. It requests details about students' medical conditions, medications, immunizations, and any special instructions if medical attention is needed. Parents must provide their contact and insurance information. By signing, parents give permission for their children to participate in all activities and consent to medical treatment if needed. They also release the church from liability and responsibility for medical costs. The information will be kept confidential.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    47 views4 pages

    Medical Waiver 2014-2015

    Uploaded by

    api-73377093
    This form collects medical, contact, and insurance information for students attending events at The Grace Place and Salem Baptist Church for the 2014-2015 school year. It requests details about students' medical conditions, medications, immunizations, and any special instructions if medical attention is needed. Parents must provide their contact and insurance information. By signing, parents give permission for their children to participate in all activities and consent to medical treatment if needed. They also release the church from liability and responsibility for medical costs. The information will be kept confidential.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    2014-2015 School Year

    Medical, Surgical Waiver


    & Picture/Video Release
    Information
    The 2014-2015 (June 2014 May 2015) School Year Medical, Surgical Waiver & Picture/Video Release form will apply to all student
    events, trips and projects for the 2014-2015 (June 2014 May 2015) school year. This will give The Grace Place, Salem Baptist Church, an
    adequate, current, and usable record of each students medical information, and will give hospitals information they need to have, including
    parental permission, in case any student needs medical attention. Please submit a photo copy of your insurance card with these forms to the
    church office. All infor mation is kept confidential and secur e. Please be thor ough with each answer .

    ***** It is the responsibility of the parent or legal guardian to keep this information current.*****

    Parent/Guardian Information
    Mother/Guardian Name ____________________________________ Father/Guardian Name _____________________________________
    Address________________________________________________________ City _____________________________ Zip______________
    Home Phone ____________________ Mother/Guardian Cell Phone_________________ Father/Guardian Cell Phone__________________
    Second Contact Name & Number _____________________________________________________________________________________
    Parents Email Address_______________________________________________________________________________________________

    Medical Information
    Family Physician_______________________________________________________________ Phone _____________________________
    PERSON 1:
    Participants Name_________________________________________________________ Birth Date _____________________________
    List any physical limitations or conditions that the participant has such as: allergies, asthma, nervousness, headaches, seizures, etc.
    or write NONE_________________________________________________________________________________________________
    List any medications the child is currently taking: ______________________________________________________________________
    List over the counter medications that staff/volunteers may give child (i.e. Ibuprofen, Tylenol, Rolaids etc.) _____________________
    ________________________________________________________________________________________________________________
    Should the participant at any time require medical attention, list any special instructions which the participant might require such as being
    allergic to penicillin, having a rare blood type, etc. or write NONE
    _________________________________________________________________________________________________________________
    Current Immunization (give date or write none): _____________Tetanus: __________________________

    2014-2015 School Year


    Medical, Surgical Waiver
    & Picture/Video Release
    PERSON 2:
    Participants Name_________________________________________________________ Birth Date _____________________________
    List any physical limitations or conditions that the participant has such as: allergies, asthma, nervousness, headaches, seizures, etc.
    or write NONE_________________________________________________________________________________________________
    List any medications the child is currently taking: ______________________________________________________________________
    List over the counter medications that staff/volunteers may give child (i.e. Ibuprofen, Tylenol, Rolaids etc.) _____________________
    ________________________________________________________________________________________________________________
    Should the participant at any time require medical attention, list any special instructions which the participant might require such as being allergic to penicillin, having a rare blood type, etc. or write NONE
    _________________________________________________________________________________________________________________
    Current Immunization (give date or write none): _____________Tetanus: __________________________

    PERSON 3:
    Participants Name_________________________________________________________ Birth Date _____________________________
    List any physical limitations or conditions that the participant has such as: allergies, asthma, nervousness, headaches, seizures, etc.
    or write NONE_________________________________________________________________________________________________
    List any medications the child is currently taking: ______________________________________________________________________
    List over the counter medications that staff/volunteers may give child (i.e. Ibuprofen, Tylenol, Rolaids etc.) _____________________
    ________________________________________________________________________________________________________________
    Should the participant at any time require medical attention, list any special instructions which the participant might require such as being allergic to penicillin, having a rare blood type, etc. or write NONE
    _________________________________________________________________________________________________________________
    Current Immunization (give date or write none): _____________Tetanus: __________________________

    2014-2015 School Year


    Medical, Surgical Waiver
    & Picture/Video Release
    PERSON 4:
    Participants Name_________________________________________________________ Birth Date _____________________________
    List any physical limitations or conditions that the participant has such as: allergies, asthma, nervousness, headaches, seizures, etc.
    or write NONE_________________________________________________________________________________________________
    List any medications the child is currently taking: ______________________________________________________________________
    List over the counter medications that staff/volunteers may give child (i.e. Ibuprofen, Tylenol, Rolaids etc.) _____________________
    ________________________________________________________________________________________________________________
    Should the participant at any time require medical attention, list any special instructions which the participant might require such as being allergic to penicillin, having a rare blood type, etc. or write NONE
    _________________________________________________________________________________________________________________
    Current Immunization (give date or write none): _____________Tetanus: __________________________

    PERSON 5:
    Participants Name_________________________________________________________ Birth Date _____________________________
    List any physical limitations or conditions that the participant has such as: allergies, asthma, nervousness, headaches, seizures, etc.
    or write NONE_________________________________________________________________________________________________
    List any medications the child is currently taking: ______________________________________________________________________
    List over the counter medications that staff/volunteers may give child (i.e. Ibuprofen, Tylenol, Rolaids etc.) _____________________
    ________________________________________________________________________________________________________________
    Should the participant at any time require medical attention, list any special instructions which the participant might require such as being allergic to penicillin, having a rare blood type, etc. or write NONE
    _________________________________________________________________________________________________________________
    Current Immunization (give date or write none): _____________Tetanus: __________________________

    2014-2015 School Year


    Medical, Surgical Waiver
    & Picture/Video Release
    Medical Insurance Information
    Company Name _____________________________________________________________Group # ____________________
    Policy # ____________________________________________________________ Phone #____________________________
    Policy Holders Name ________________________________________________ Check here if no medical insurance ________

    Waiver

    ***** To be filled out by parents or legal guardian of participants under 18 years of age *****

    I, __________________________________________________ the parent and/or legal guardian of,


    __________________________________________________, __________________________________________________,
    __________________________________________________, __________________________________________________,
    a minor, hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give my child, the said minor, permission to
    participate in any and all activities at and with The Grace Place, Salem Baptist Church, in which he/she, with my approval, registers to participate in.
    I further expressly grant my permission for my child to participate in all activities while an active participant in trips and church events. In the event that
    there rises an emergency, necessitating medical, surgical attention, I hereby consent and give my permission to The Grace Place, Salem Baptist Church, its
    representatives, sponsors, and attending physicians, to make such decisions and to perform such medical treatment and/or surgery upon said minor which
    may in their sole discretion be necessary and proper under the circumstances. I, the undersigned parent and/or legal guardian of said minor, do release,
    acquit, discharge, and covenant The Grace Place, Salem Baptist Church, from any and all actions and causes of actions, related risks and dangers, including
    negligence, damages, liabilities arising out of the treatment of any sickness or accident, and financial responsibility for all medical treatment of any sickness or
    accident, provided during the attendance of any trips or events.
    I also assume responsibility for providing any transportation from the location event should it be necessary for disciplinary reasons.

    __________________________________________________________________
    Parent or Legal Guardian Signature:

    ___________________
    Date

    I give The Grace Place Church, Salem Baptist Church, the permission to use any pictures taken of our family for online websites and any other
    type of media marketing with the full knowledge that our images are not being used for financial gain.

    __________________________________________________________________
    Parent or Legal Guardian Signature:

    ___________________
    Date

    TO BE FILLED OUT BY STAFF/VOLUNTEERS WHO ARE CURRENTLY 18 YEARS OF AGE OR OLDER.


    I, ________________________________________________, ________________________________________________, am 18 years of age or older
    and have read the Medical and Surgical Waiver for minors and agree to the same terms. I hereby release, acquit, discharge, and covenant to indemnify
    and hold harmless The Grace Place, Salem Baptist Church, from any and all actions and causes of actions, related risks and dangers, including negligence, damages, liabilities arising out of the treatment of any sickness or accident, and financial responsibility for all medical treatment of any sickness
    or accident, provided during the attendance of any trips or events.
    I give The Grace Place Church, Salem Baptist Church, the permission to use my picture for online websites and any other type of media marketing with
    the full knowledge that my image is not being used for financial gain. _________ (Initial)
    I also assume responsibility for providing any transportation from the location event should it be necessary for disciplinary reasons.

    __________________________________________________________________
    Adult Staff/Volunteer Signature:

    __________________________________________________________________
    Adult Staff/Volunteer Signature:

    ___________________
    Date

    ___________________
    Date

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