Medical Waiver

Jamestown Christian Church Permission/Media/Medical Waiver
Youth Participants
Name of Child (please print)______________________________________________________________________

Parent(s) and/or legal guardian(s) of child participant __________________________________________________
Address ____________________________________________________________________________________
Home Phone (_____) ___________________________ Parents Cell (_____) _____________________________
Students Cell (____)_______________________Birth Date ______________ Academic Grade _______________
School__________________________________ Parent Email__________________________________
Functions and Activities
It is my understanding that participating in the programs and recreational and other activities of JAMESTOWN CHRISTIAN
CHURCH is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated
with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to
transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent
in these activities of which I may not be presently aware.
Release of Liability
By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of withstanding both
the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child
participating in the activities, whether such risks are known or unknown to me at this time. I further release JAMESTOWN
CHRISTIAN CHURCH and its ministers, leaders, employees, volunteers, and agents from any claim that my child may have
or that I may have against them as a result of injury or illness incurred during the course of participation in the
activities. This release of liability shall exclude any gross claims of negligence. This release of liability is also intended
to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against
JAMESTOWN CHRISTIAN CHURCH or its ministers, leaders, employees, volunteers, or agents.
I further agree to indemnify and hold harmless JAMESTOWN CHRISTIAN CHURCH and its ministers, leaders, employees,
volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result
of injury or illness of my child during such activities.
First Aid and Emergency Medical Treatment
I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical
treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of
JAMESTOWN CHRISTIAN CHURCH to seek and secure any needed medical attention or treatment for the child named
above, including hospitalization, if in the agent's opinion such need arises. In doing so I agree to pay all fees and costs
arising from this action to obtain medical treatment.
I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment,
including surgery and, again, I agree to pay for the medical treatment.
Special Events and Field Trips
I understand that the child named above may be participating in local service projects and fellowship events during
church youth events. I understand that during this period my child/ward may take part in activities such as: minor yard
work, cleaning, painting, and other activities consistent with the purposes of the church.
Informational Notes
All drivers during youth ministry-related events must be 21 years of age with a good driving record. All drivers of the
church van must be 25 years of age and must meet the stringent requirements of our insurance company, including a
Department of Motor Vehicles background check. While we understand that older youth may drive themselves to and
from events, we will not give any youth permission to ride home with any other youth; this must come from the parents
themselves.
Health Insurance Information
Insurance Company __________________________________ Policy Number ____________________________
Insurance Company Phone Number ___________________________________________
Medical Doctor _________________________________ Phone number _________________________________
Emergency Contacts
Names of persons and telephone numbers to call in case of emergency:
Name ______________________________________
Relation ______________________________________
Home Phone ________________________________ Work Phone _____________________________________

Name ______________________________________
Relation ______________________________________
Home Phone ________________________________ Work Phone _____________________________________

Medical History
Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.):
Other Information
Other information leaders should know about the child or adult participant:
Authorization for Media Release
Jamestown Christian Church may post a photograph and/or video of my child on the churchs website or use a
photograph of my child in their publications. I understand that photos will not be labeled with names.
I ask that Jamestown Christian Church not post photographs and/or videos of my child on the churchs website
or use a photograph of my child in their publications
For Use Only if the Participant is a Minor
I represent that I am the parent/guardian of _________________________, who is under 18 years of age. I have read
the above Permission/Waiver Form and am fully familiar with the contents thereof.
I give permission for the child named above to participate in the activities of Jamestown Christian Church, including
any special events/activities described above. In consideration for allowing the participation of the child in the activities
of Jamestown Christian Church, I hereby consent to the Permission/Waiver Form, including the Release of Liability
above, on behalf of the child, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs,
legal representatives, successors, and assigns.
Signature of Parent or Legal Guardian _____________________________
Date_________________________
Print Name of Parent or Legal Guardian _____________________________________________

Witness Signature ___________________________________________
Date_________________________
Youths Agreement
I agree to participate in the functions and activities of Jamestown Christian Church, to cooperate with the leaders and
other young people, and to conduct myself as a Christian. I promise to respect God, respect myself, respect other
persons, and respect property. If it becomes necessary for me to be sent home early from an event, this will be done at my
parents expense. I understand that my continued participation in church activities depends on my support of this
agreement.
Signature of youth _______________________________________________ Date_________________________
*Adapted from Plymouth First United Methodist Church

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Jamestown Christian Church Permission/Media/Medical Waiver

Name of Child (please print)______________________________________________________________________

Home Phone Work Phone _____

Home Phone Work Phone _____

Print Name of Parent or Legal Guardian _____________________________________________

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