Medical And Liability Release Form

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MEDICAL AND LIABILITY RELEASE FORM
Town North Presbyterian Church
Name ______________________________________________ Birthdate / Age __________________
Address ____________________________________________________________________________
City _____________________________ Zip _________________ Phone _______________________
Parent’s Name ___________________________________ Social Security # ____________________
In Emergency, notify ______________________________________ Phone _____________________
Name of your Physician _______________________________________________________________
City _______________________________ Zip _______________ Phone _______________________
HEALTH HISTORY:
allergies and other conditions
___Insect Allergies
___Drug Allergies
___Other Allergies
___Frequent Colds
___Heart
___Athsma
___Physical Handicap
___Epilepsy
___Hay Fever
___Frequent stomach upsets
___Diabetes
If you checked any of the above, please give details (i.e., include normal treatment of allergic reactions):
____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date of last tetanus shot: _____________________________________
Name and dosage of any medications that must be taken: ____________________________________________
__________________________________________________________________________________________
Swimming Restrictions: ____ No ____Yes Explain ________________________________________________
Activity Restrictions: ___No ___Yes Explain______________________________________________________
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 your child is on a church-related activity.
Do you have health/medical insurance? ___Yes ___No
If “yes”, Name of Co.: ____________________________________ Policy # _____________________________
Address:____________________________________________ Phone: _________________________________
Consent to Medical Treatment: In the event a Parent or Guardian cannot be reached in an emergency, I
hereby give permission to the physician, dentist or other health care provider selected by the authorized
representative of Town North Presbyterian Church, Richardson, TX to provide medical treatment for my
child deemed medically necessary, including but not limited to hospitalization, injections, medication,
anesthesia, and surgery.
R
L
I
: I
ELEASE OF
IABILITY AND
NDEMNITY
AGREE TO ACCEPT AND TO ASSUME FULL RESPONSIBILITY FOR ALL RISKS
C
AND HAZARDS INHERENT IN AND ASSOCIATED WITH PARTICIPATION IN
HURCH RELATED ACTIVITIES BY MY SON OR
. I
,
C
DAUGHTER
HEREBY AGREE TO INDEMNIFY
HOLD HARMLESS AND DEFEND THE
HURCH AND EACH OF ITS
,
,
,
,
,
EMPLOYEES
OFFICERS
REPRESENTATIVES AND VOLUNTEERS AGAINST ANY LIABILITY
COST
LOSS
CLAIMS AND
,
,
C
ACTIONS
INCLUDING NEGLIGENCE
BASED UPON OR SUSTAINED IN CONNECTION WITH PARTICIPATION IN
HURCH
.
RELATED ACTIVITIES
T
M
C
, R
L
HE UNDERSIGNED UNDERSTAND THAT THEY ARE SIGNING THIS
EDICAL
ONSENT
ELEASE OF
IABILITY AND
I
_________________________________________________.
NDEMNITY AGREEMENT IN BEHALF OF
(N
)
AME OF MINOR
P
L
G
S
_______________________________________________
ARENT OR
EGAL
UARDIAN
S
IGNATURE
(seal)
STATE OF ______________________
COUNTY OF ____________________
Before me, a notary public, on this day appeared _____________________________ known to me to be the
person whose name is subscribed to the foregoing document and being by me duly sworn, declared that the
statements therein contained are true and correct.
Given under my hand and seal of office this _____ day of ______________________, AD. _____.
Notary Public Signature __________________________________ my commission expires ________
Notary Public typed or printed Signature ____________________________
Please send form back to Town North Presbyterian Church C/O Carl Hinds or Brian Moore, 1776 N. Plano Rd., Richardson, TX 75081
T
M
R
F
I
G
U
S
30, 2001
HIS
EDICAL
ELEASE
ORM
S
OOD
NTIL
EPTEMBER

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