WPC Youth ministry Medical Release Form Student's Information Today's Date MM DD YYYY Student's Name * First Name Last Name Gender Male Female Student's Birthday * MM DD YYYY School Grade (Fall 2023) * 6th 7th 8th 9th 10th 11th 12th Student Health History Allergies Drug allergies Food allergies Hay Fever Student Health History - Major Conditions Diabetes Physical Disability Nervous Disorder Activity Restrictions Chronic Asthma Emotional Disability Seizure Disorder Epilepsy Mental Health Issue Other Details of all checked items Please explain each of the areas checked Medications Please list all medications currently being taken Parent's Information Mother/Guardian's Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Father/Guardian's Name * First Name Last Name Address Please fill if different from mother's address. Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Emergency Contact Emergency Contact * If parents can not be reached First Name Last Name Phone Number * (###) ### #### Relationship * Medical Insurance Insurance Company Policy Number Primary Doctor's Name First Name Last Name Phone Number (###) ### #### Medical Release and Consent Release, Waiver & Indemnity Agreement * I understand and agree to release, waive, indemnify and hold harmless Westminster Presbyterian Church of Escondido (the “Church”), and its directors, officers, employees, agents and representatives, with respect to any claims, costs, damages, losses, injuries, causes of action or liability based on or arising out of the participation of the above-named child (the “Child”) in the above-described activity (the “Activity”). This release, waiver and indemnity includes the Participant and the Participant’s parents, guardians, heirs, successors, assigns and estate. I also authorize the duly authorized agents and representatives of the Church to render or obtain such emergency medical care or treatment as may be necessary for the Participant should any injury, harm or accident occur to the Child while participating in the Activity. I/We understand that there are risks associated with any medical procedure and, knowing these risks, I/we agree to assume the risks. I further state and acknowledge that I/we are authorized to sign this Agreement, that I understand the terms herein are contractual and not a mere recital, that I/we have signed this document of my/our free act and volition, having read it carefully before signing it. A copy of this Waiver & Release is as valid as an original. By selecting "yes" from the dropdown menu and typing my/our name below, I/we have executed this affirmation and release. I/we declare that the name below is my/our own and by typing it into the form, I/we am officially signing this form. I/we, the undersigned am/are responsible for decisions for the Child and am/are authorized to consent to services to be rendered, and no other consent is required by law. Yes Covid19/Illnesses I understand that Westminster Presbyterian Church will do its best to maintain current CD and California state guidelines in regard to COVID19, including, but not limited to, wearing face coverings and maintaining 6 feet distance between persons. I also understand that, despite the best efforts of WPC, children/youth may remove their own masks and/or come closer than 6 feet to another person. I release WPC from all responsibility if my child contracts COVID19 during any youth activities or events. Yes Media Consent * I hereby give my full consent to Westminster Presbyterian Church of Escondido (WPC) and its ministries to record (video, photograph, audio, recording or other) my and my child's participation in any programs or events associated with WPC. Further, I hereby assign to WPC the exclusive rights to use said images, video, photography, audio recordings or other, for promotional and educational use. Yes No Parent/Guardian's Signature * Type name here to sign electronically. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury that I am authorized to enter into this Waiver and Release and that no other signature is required for this Waiver and Release to have legal effect. Signed on behalf of: * Type the Minor Child's Full Name Please add me to the mailing list E-Mail is our main form of communication. By checking the box below you are opting in to receive regular information emails regarding our events, ministry and activities. Please send me emails Thank you!
