Cce Youth Ministry Liability Release Form (Page 2 of 2) in pdf

______________________________

_____________________________________

(Type/print name of youth participant)

Type/print Name of Parent or Legal Guardian)

______________________________

____________________________________

________

Signature of youth participant

Signature of Parent or Legal Guardian

Date

I have read and understand the foregoing release on the first page hereof and consider this release as

legal and binding by witness of my signature.

HEALTH AND MEDICAL INFORMATION

Name__________________________ _____ _____

Date of Birth ________________________

Street Address______________________________ __ City/County Zip Code________________

Father’s Name_________________ ______ __

Mother’s Name ___ _____________________

Address______________________ ________

Address_____________________________

(if different from above)

(If different from above)

Home #__________ __Cell #________ ___

Home #_____________Cell#____________

Primary Physician_____________________ ___________ Phone #________________________

List any medication participant is currently taking:_________________________________________

List any allergies of participant:_______________________________________________________

List any medical condition we should be aware of:__________________________________________

List any restrictions that should be observed by participant:___________________________________

List any OTC medications that participant should not receive:__________________

INSURANCE INFORMATION

Participant is covered by medical insurance and a copy of his/her health insurance card evidencing such

coverage is attached hereto and made part hereof.

Emergency CONTACT INFORMATION

Person to Contact in Case of Emergency if Parents Cannot Be Reached

Name________________________________ Relationship______________ Phone#___________

Name________________________________ Relationship______________ Phone #___________

4/2012

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Cce Youth Ministry Liability Release Form Page 2