2018-19 Medical & Participation Release 18+

Please complete the following information about yourself. You must have a Student Ministries Medical Release & Participation Agreement on file to participate in off campus activities, including camps. This release is valid from June 1, 2018 thru May 31, 2019:
*First Name:
*Last Name:
*Zip Code:
*Life Stage:
*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):
*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:
By signing below, 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 me should I 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 my emergency contact 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 are unsuccessful:
By signing below, the participant 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 of Red Mountain Community Church, the participant accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant 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 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 me Tylenol (or similar pain medication) if, in the opinion of the adult leaders of the activity, I am in need of such over-the-counter medication. (If you do not authorize, type NO in the field below.):
OTC Med Authorization:
By signing below, I agree to pay any expenses including the cost of being sent home if discipline is deemed necessary. I further understand that in the interests of providing necessary accountability, the attending Pastor may search my belongings if there is reasonable suspicion that any prohibited items have been brought. I also understand that the Pastor will always act in my best interest by handling any search quietly and discretely with at least one other staff member present. In the event any of the prohibited items are found, the Pastor will, after conferring with the Executive Pastor, make a decision regarding the best course of action for my emotional and spiritual growth:
By signing below, I hereby give Red Mountain Community Church the right to record photographs and video footage of myself 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, 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 person listed above and have the authority to enter into this agreement:
*Digitial Signature of Participant (First, Middle Initial, Last):
*Signed this day: