This release is valid for one year: June 2005-June 2006
First Presbyterian Church Emergency Medical Form and Liability Release Statement
Please make a copy of your medical/drug card on the back of this form.
In consideration of the acceptance of my child or ward to participate in the activities sponsored by The First Presbyterian Church of Findlay, Ohio, I/we, for myself and for my child or ward and his or her executors, administrators, heirs, and assigns, do hereby release, discharge, indemnify and save and hold harmless The First Presbyterian Church, Findlay, Ohio, its trustees, session members, elders, ministers, members, agents, employees, volunteers, supervisors of the activity and associated functions, providers of transportation and those in any way associated therewith, whether individually or jointly and severally from and against any and all claims, suits, damages, demands, actions, liabilities, losses or expenses whatsoever may arise at any time from said child’s or ward’s participation in such activity to include but not limited to injuries sustained during the activity or associated functions.
PLEASE CLEARLY PRINT THE FOLLOWING INFORMATION:
Child’s Name Grade
Address Age M F
City State Zip Birthdate
Parent/Guardian(‘s) Name Phone
Address Cell
Employer Phone
Parent/Guardian(‘s) Name Phone
Address Cell
Employer Phone
Current Medications & dosages(Youth)
Medications youth cannot take
Allergies
Date of last Tetanus Shot (please update if needed)
Family Physician Phone
Address
Family Dentist Phone
Address
Health Insurance Carrier Phone
Address
Policy Number Group Number Policy Holder’s ID
Relationship to Policy Holder If this youth is not currently covered, please check here:
In the event of an emergency, where the parent(s) or guardian(s) listed above cannot be reached, please contact:
Name Relationship
Address
Telephone: Home Cell Work
Name Relationship
Address
Telephone: Home Cell Work
PLEASE TURN OVER FOR SIGNATURE RELEASE AND NOTARIZATION.
In the event that reasonable attempts to contact me/us have been unsuccessful,
(1) I hereby give my consent for the adult leaders of First Presbyterian Church to sign for emergency care for my child as deemed necessary by the primary physician or dentist listed, his or her designee, or, in the event that this physician or dentist is inaccessible/out of area, another licensed physician or dentist.
(2) I authorize the transfer of my child to any hospital that is reasonably accessible. This authorization does not cover surgery unless deemed necessary by two physicians or dentists PRIOR to the performance of such surgery. Should it be necessary for the youth to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.
(3) The undersigned gives permission for this youth to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities at First Presbyterian Church.
(4) Should this youth injure self, others, or damage property of the Church, its agents, representatives, or others, the undersigned hereby agrees to pay all damages required to save, hold harmless and indemnify First Presbyterian Church, its agents, representatives and those injured or damaged from all costs, claims, suits, damages, demands, actions, liabilities and losses whatsoever it or they may sustain as a result of the negligent, willful or intentional acts of this youth.
Signature of Parent or Legal Guardian
Witnessed by Notary Public on this day of , 200___.
Signed , Notary Public.
My Commission Expires . SEAL
PLEASE MAKE A COPY (FRONT & BACK) OF YOUR MEDICAL/PRESCRIPTION CARD BELOW.