Emergency Form & Liability Release
NOTE: This form is intended to be filled out by the parent/legal guardian of the participating child/teen. For full disclosure on all our privacy practices, please see our Privacy Policy linked at the bottom of this page.
Name of Participant:*
Date of Birth:*
Parent or Guardian:*
Address:*
City:*
State:*
Zip Code:*
Day Phone:*
Evening Phone:*
Cell Phone:*
Alternate Emergency Contact:*
Phone:*
Medical Insurance Company:*
Policy Number:*
Check any of the following conditions that apply:
 Asthma
 Diabetes
 Epilepsy
 Heart Condition
 Hypertension
 Seizures
Allergies:*
Special Conditions:*
Medications:*
PARENTAL CONSENT

I, as parent or guardian of the aforementioned minor, do hereby authorize adult workers with the youth of the Visalia Community Church of Christ to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services.
AGREEMENT AND RELEASE FROM LIABILITY


1. Explanation of Form. This form provides medical release in case of an emergency. It allows any medical care to be administered by those chaperoning youth activities of the Visalia Community Church of Christ. It applies to any and all activities in which a student participates. It will be carried to all youth events. No student may participate in any activity without having this form returned to the appropriate person(s).


2. Assumption of Risk. I AM AWARE THAT THE VISALIA COMMUNITY CHURCH OF CHRIST YOUTH GROUP ACTIVITIES COULD BE HAZARDOUS. I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES AND HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH, AND VERIFY THIS STATEMENT BY SIGNING AT THE BOTTOM.


3. Release From Liability. As consideration for being permitted by the Visalia Community Church of Christ or one of its affiliated organizations to participate in these activities and use their facilities, I hereby agree that I, my assignees, heirs, guardians, and legal representatives will not make a claim against, sue, or attach the property of the Visalia Community Church of Christ or any of its affiliates for injury or damage resulting from the negligence or other acts, howsoever caused, by any employee, agent, or contractor of the Visalia Community Church of Christ or its affiliates as a result of my participation in youth activities. I hereby release the Visalia Community Church of Christ and its affiliates from all actions, claims, or demands that I, my assignees, heirs, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in the Visalia Community Church of Christ youth activities.


4. Knowing and Voluntary Execution. I HAVE READ THIS FORM AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE VISALIA COMMUNITY CHURCH OF CHRIST AND ITS AFFILIATES. I ACKNOWLEDGE THAT I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES AND SIGN THIS AGREEMENT OF MY OWN FREE WILL.*
Electronic Signature:*
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above parental consent and agreement and release from liability.*
Receipt/Confirmation Email Address:


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