GBC Children & Youth Medical Release Form

All children and youth activities, operated by Gwathmey Baptist Church (the “Church”), under the supervision of the staff and volunteers of Gwathmey Baptist Church require the completion and acceptance of a medical release form prior to participation. Medical Release Forms are valid for one calendar year. Please add the child to whom this form applies.

Your name *

Email address *

Please Add the Child(ren) & Youth to Whom This Form Applies

Household members

Address

Phone number

Agreement to Release

I, the parent/guardian, for the student indicated above, apply to Gwathmey Baptist Church to participate in the activity described and indicated event or activity. I acknowledge and agree to, and represent, the following for myself and the student, in consideration of the opportunity to be provided by the Church (contingent upon its agreement to my child's and/or my participation).

Acknowledgment of Risks. I acknowledge that participating in the Activity involves risks of serious damage and harm to persons and property, and even death, and I assume those risks, including risk arising from acts or failures to act of the Church.

Information Relied on by Church. I am the parent or legal guardian for the student for whom this document is signed. The student is in good health and sound mind. If necessary, I have discussed or will discuss with my physician the student's participation in the Activity, and the student has received or will receive any vaccination or other recommended prerequisite medical treatment my physician deems necessary. The student will participate in the Activity only if I have received my physician's approval, if I deem it necessary, and believe that the student is able to participate without harm, I acknowledge that the Church will not assess or approve the student's fitness for participation. I am under no force or duress of any kind to compel the student's participation in the Activity or my signing of this document.

Release. This document is intended to absolve the church of any liability of the student that is related to the student's participation in the activity. Accordingly, I hereby release the Church from, waive, and will never sue the Church for, any damage (whether damage to or loss of property, finances, life, body, mind, or emotions), cost, suit, demand, claim, or other liability, that arises or is alleged to arise or in connection with the student's participation in the Activity. Such liability includes any liability that arises or is alleged to arise from the Church's negligence (but not its willful and wanton misconduct). Such liability also includes any liability that arises or is alleged to arise from claims for contribution by another that the student or I have sued or from whom the student or I have received compensation.

Medical Permission. I give my permission for the student to be treated for illness or injury sustained while participating in the Activity, including by the administration of emergency anesthesia or surgery; and authorize the adult leaders of the Activity to act on my behalf in ordering such treatment.

Definitions. (a) References to “met,” “my,” and “I” shall include and bind the student, my spouse, any parent of the student for whom this document is signed, any guardian or other person with responsibility for the care and supervision of such student and any insurer, heir, estate, legal representative, executor, administrator, successor, or assign of me or such student. (b) “Participation” or “participating” in the activity includes planning and preparing for, traveling to, and traveling from, as well as participating in the Activity. (c) The “Church” includes (i) its affiliates, and institutions cooperating in the Activity; (ii) the trustees, elders, officers, employees, volunteers, and agents of the Church or such affiliate or institution; and (iii) the spouses, insurers, heirs, estates, legal representatives, executors, administrators, successors,
estates, and assigns of any of the foregoing.

I agree that typing my name below serves as my official signature and agreement to this release. *

Today's Date *

Brief Medical History

In the event of an emergency, the most accurate and updated information will be extremely
helpful for us in providing the best care for your student.

List all Medical Conditions and any current Medication regimens (if none, type NONE): *

List all Known Allergies (if none, type NONE): *

Alternate Emergency Contact (Other Than Signer of the Release)

Full Name *

Relationship to Student *

Phone Number *

Damage Responsibility Agreement

I, the parent/guardian, take full responsibility for any damages incurred by my son/
daughter at any Gwathmey event or trip, including but not limited to church/host home property, hotel,
meeting space, and/or public areas. I agree to pay for those damages incurred.

I agree that typing my name below serves as my official signature and agreement to this release. *

Today's Date *

Consent For Release to Media

I hereby give my full consent to Gwathmey Baptist Church to record my son/daughter's participation in any programs or events associated with Gwathmey. I understand that his/her image may be used, but his/her name or personal information will never be shared publicly without additional, separate consent. I know that Gwathmey Baptist Church will not sell, give or in any way share the student‟s personal information with any other program, organization, or agency.

I agree that typing my name below serves as my official signature and agreement to this release. *

Today's Date *

Student Insurance Information

Student's Full Name *

Student's Date of Birth *

Insurance Carrier *

Policy Number/Group Number *

Policy Holder's Name *

Policy Holder's Date of Birth *

Secondary or Prescription Coverage (if applicable)

Secondary Insurance Policy Number/Group Number

Secondary Insurance Policy Holder's Name

Secondary Insurance Policy Holder's Date of Birth

YOU MAY BE ASKED TO SHOW INSURANCE CARD

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Please Add the Child(ren) & Youth to Whom This Form Applies

Agreement to Release

Brief Medical History

Alternate Emergency Contact (Other Than Signer of the Release)

Damage Responsibility Agreement

Consent For Release to Media

Student Insurance Information

***YOU MAY BE ASKED TO SHOW INSURANCE CARD***

YOU MAY BE ASKED TO SHOW INSURANCE CARD