18/19 Medical & Participation Release (CM)

Please complete the following information about yourself. You must have a Children's Ministry Medical Release & Participation Agreement on file to participate in on and off campus activities, including camps. This release is valid from June 1, 2018 thru May 31, 2019:
CHILD'S INFORMATION:
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip Code:
*Grade (2018-19 school year):
*Date of Birth (mm/dd/yyyy):
*Home Phone:
*Medical Insurance Company:
*Policy Number:
*Allergies: Medicine or Other:
*Current Medications:
NOTE: If you are taking any medication, additional paperwork will be emailed to you prior to the event or camp:
Date of Last Tetanus Immunization (mm/dd/yyyy):
PARENT/GUARDIAN INFORMATION:
*Primary Adult:
*Primary Adult Cell Phone:
*Relationship to Student (primary adult):
Secondary Adult:
Secondary Adult Cell Phone:
Relationship to Student (secondary adult):
Mailing Address (if different from student):
*Main Email Address:
Emergency Contact (other than above):
Relationship to Student (emergency contact):
*Emergency Phone:
MEDICAL RELEASE:
By signing below, as the parent or legal guardian, having legal custody of the above named youth, I give permission for a licensed doctor, physician, or emergency treatment center, selected by the person in charge of any Red Mountain Community Church event, to administer the necessary attention and aid immediately to our child should he/she become injured or sick at any event during the dates of June 1, 2018 thru May 31, 2019 and to do so without having to wait until I have been contacted. I furthermore understand that I will be held liable for the expense of that treatment. I consent to X-rays, examination, anesthetic, medical or surgical diagnosis, treatment, and hospital care. I understand the event leader will endeavor to reach me should the nature of the injury or illness warrant it. However, I will not hold any of the event personnel responsible if efforts to contact me are unsuccessful:
By signing below, the participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury associated with participation with activities sponsored by Red Mountain Community Church. Except for gross negligence on the part Red Mountain Community Church, the participant‘s parent/guardian accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent/guardian) promises to hold harmless Red Mountain Community Church and its representatives for the any injury related to the activity. If a dispute over the agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable arbitration process:
By signing below, I also authorize, in advance, the Red Mountain Community Church leaders to give my son/daughter Tylenol (or similar pain medication) if, in the opinion of the adult leaders of the activity, my child is in need of such over-the-counter medication. (If you do not authorize, type NO in the field below.) :
OTC Med Authorization:
PHOTOGRAPHY RELEASE:
By signing below, I hereby give Red Mountain Community Church the right to record photographs and video footage of my child(ren) and to use, re-use, publish and re-publish in whole, or in part for any purpose, including, but not limited to illustration, training or promotion. I hereby release and discharge Red Mountain Community Church from any and all claims, and demands arising out of or in conjunction with the use of the images. I understand that, in the course of events at Red Mountain Community Church and for the purpose of fostering positive relationships, students or volunteer staff may take photographs, taken in a public setting, of my child(ren) along with others and post them on social media (Facebook, Instagram, etc.). (If you do not authorize, type NO in the box below.):
Photography Release Authorization:
By entering today's date and typing my first name, middle initial and last name in the digital signature box I am signifying that I am the parent or legal guardian of the student listed above and have the authority to enter into this agreement:
*Digitial Signature of Parent/Guardian (First, Middle Initial, Last):
*Signed this day: