Beach Freeze Medical Release Form

HARBOR COVENANT CHURCH

MEDICAL RELEASE AND PARENTAL PERMISSION FORM

Good For All Youth Trips and Events Through August 31, 2013

                                                                                     

Student Name ______________________________ Age ____ Grade ____  Gender ______

Date of Birth _______/_______/__________  High School Graduate Year _____________

Address _____________________________________ City ________________ Zip _______

Parent’s Names _________________________________________ Home # _____________

Parent’s Email __________________________________________ Cell # ______________

Parent’s Address ______________________________ City _______________ Zip _______

Alternate Contact ___________________ Phone # _____________ Work # ____________

MEDICAL INFORMATION:

Allergies: __________________________________________________________________

Medication Being Taken: _____________________________________________________

Physical Handicaps or Limitations: _____________________________________________

Medical Insurance Company: __________________________________________________

Policy Number: ________________________  Member’s Name: _____________________

Primary Physician: ________________________ Physician’s Phone# _________________

Any additional information should be provided on the back of this release form.

I give permission for ______________________________ (student’s name) to travel with Harbor Covenant Church (Gig Harbor, WA) from September 1, 2012 – August 31, 2013.

I hereby release Harbor Covenant Church, its staff and sponsors, from responsibility and liability for any injury and illness that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as an agent for me, to consent to any x-ray examination; medical, dental or surgical diagnosis; treatment; and hospital care as advised by a physician, surgeon or dentist (as appropriate) as listened to practice under the laws of the state/province where the services are rendered, either at the doctors office or in any hospital. I expect to be contacted as soon as possible.

I also understand that if my child is disruptive, brings alcohol, drugs, weapons, causes any injury to themselves or others, or engages in any unacceptable behavior, I will be responsible to remove my child from this activity and transport them immediately back to Gig Harbor.

The undersigned gives permission to Harbor Covenant Church to photograph his or her son or daughter and use the resulting photographs for any purpose that Harbor Covenant Church deems proper.  (For further explanation, please contact us.)

_______________________________________________________  ______/_____/______

                 Parent or Legal Guardian                                          Date

Harbor Covenant Church 5601 Gustafson Dr. NW, Gig Harbor, WA 98335 – (253) 851-8450