Thrive Medical and Liability Release Form

Please fill out this form and click submit.
2018-2019 School Year

Student Information

 
 
 
 
Please select all that apply.
 
 
Parent Information

 
 
 
 
Emergency Contact

In case parent/ guardian number does not answer please notify:
 
 
 
 
 
Health History

 
 
 
 
Please select all that apply.
Please select all that apply.
 
Health Insurance

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.
Please select all that apply.
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.*
Liability Release

Every 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 inherent in church related activities. I also agree not to hold this church or its employees or volunteer staff liable for damages, losses, or injuries to the person or property undersigned. I understand that the signature is for both a medical and liability release.
 
 
Valid from date signed through - August 31, 2019
Medical Insurance Waiver (Only for those without insurance)

Valid from date signed through August 31, 2019 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.
 
 

Description

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