In case parent/ guardian number does not answer please notify:
Our church’s insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while you are on a church related activity.
If you do not have health insurance please fill out the additional medical
insurance waiver on the bottom of this form.
*In the event that I am unresponsive and my emergency contacts cannot be reached in an emergency during the trip specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery as deemed necessary.*
Every activity including transportation to and from activity, sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforseen events can occur. By signing this form, I agree to assume and accept all risks and hazards including but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage and financial damage. I understand that the signature is for both a medical and liability release.
Valid from date signed through - August 31, 2023
Medical Insurance Waiver (Only for those without insurance)
Valid from date signed through August 31, 2023 My child has no medical insurance. I/we, accept full responsibility for any medical expenses incurred as a result of an accident or injury that occurs during a Jamul Community Church sponsored youth activity.