Fish Tank Medical Release

2020 Fish Tank Medical Release

The Liberty Bible Church Fish Tank Medical Release Form may be submitted electronically or you can download a PDF copy (available at the bottom of this form). The PDF copy must be printed, filled it out and submitted to the church office prior to participation in an activity.

Student Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

School *

Grade *

5th 6th

Age *

Gender *

Male Female

Birth Date *

Father's Name *

First

Last

Mother's Name *

First

Last

Father's Cell # *

Mother's Cell # *

Father's Work # *

Mother's Work # *

Father's Email *

Mother's Email *

Alternate Contact Name *

First

Last

Alternate Contact # *

Insurance Carrier *

Insurance Policy Number *

Family Physician *

Physician Phone # *

Allergies *

Regular Medications *

We, the undersigned parents/guardians of the above-named participant, grant permission for the participant to participate in sponsored activities by Liberty Bible Church of the Nazarene.

We have been advised of the nature and extent of the activities that may take place and represent to you that the participant is physically and mentally able to participate in those activities.

We understand that the activity does present the risk of injury, or even death to the participant, and we have advised the participant of those possibilities. We represent to you that we and the participant assume the risk of any such injury or death, and hold you, your agents, employees and representatives harmless from any liability for injury or death to the participant while engaged in this activity which is caused or contributed to by the conduct of the participant, and agree to indemnify and defend you against any claim or liability asserted against you for any such injury or death to the participant.

We also hold you, your agents, employees and representatives harmless from any and all liability to any other person or entity arising as a result of the conduct of the participant in this activity and agree to defend and indemnify you, your agents, employees and representatives against any claim or liability arising as a result of such conduct.

If we are not personally present at these activities in which the participant is to participate, so as to be consulted in the case of necessity, you are authorized on our behalf to arrange for such medical, hospitalization, and/or surgical treatment as you may deem advisable by a licensed physician for the health and well being of the participant.

Checking "Yes" below is considered your digital signature for the purposes of this authorization. By checking here, you are consenting to the use of your digital signature in lieu of an original signature on paper. You have the right to request that you sign on a paper copy instead. By checking "Yes" below, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. Your agreement to use a digital signature with us will continue for the full duration of the 2020-2021 school year or until you notify us in writing that you no longer wish to use a digital signature.

* Indicates required field

Parent/Guardian Name *

Date Submitted *

Digital Signature *

Yes

Submission of this form indicates that you understand what is contained in this authorization. This authorization shall remain effective from September 14, 2020 until June 19th, 2021 unless sooner revoked in writing by the parent or guardian.

Submit

If you would prefer a paper copy of this form, please use the "Download File" link below. The form will need to be printed, filled out and submitted to the church office prior to participation in an activity.

2020-2021 Fish Tank Medical Release.pdf
File Size:	93 kb
File Type:	pdf

Download File