2024 Health/Medical Release

Name of Youth *

First

Last

Name of Parent/Legal Guardian Completing Form *

First

Last

Email of Parent/Legal Guardian *

Phone of Parent/Legal Guardian *

Address of Parent/Legal Guardian *

Address Line 1

Address Line 2

City

State

Zip Code

Youth Date of Birth *

List Any Allergies or Indicate N/A *

General Information-Check Any That Apply *

List any medications to be taken or indicate N/A *

List any physical or behavioral conditions that may affect or limit full participation or indicate N/A *

Is this youth free from any communicable disease? If no, explain. *

Yes
No

If above answer is no, please explain

Date of last tetanus shot *

Name and Phone of Personal Physician *

Name and Phone of Emergency Contact *

In consideration for being accepted by the Genesis Church for participation in any or all 2024 Youth activities, I, being 21 years of age or older, do for myself and on behalf of my youth-participant, do hereby release, forever discharge and agree to hold harmless Genesis Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the youth-participant that occur while said youth is participating in the trip or activity.

Furthermore, I, do for myself and on behalf of my youth-participant, hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.

The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

The health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me. I am entrusting the care of this person to the adults responsible for this activity. I hereby give permission to the physician selected by these adults to order x-rays, routine tests, and treatments for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the adults responsible for this activity, to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. I also authorize said physician or any physician or hospital who has previously treated my child, to disclose any information thus acquired, if requested, to the Genesis Church insurance carrier.

Should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all transportation costs.

"Periodically, pictures of these events will be taken and used for scrapbooks or other publications. You must give written notice to Genesis Church if you do not want your child’s picture included."

By checking this box, I attest that the information provided is accurate to the best of my knowledge. do hereby release, forever discharge and agree to hold harmless Genesis Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the youth-participant that occur while said youth is participating in any trip or activity. *

Attest/Release

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