The Crossing Medical, Photographic & Liability Release Form

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Email *

Child Name: *

Father/Legal Guardian Name: *

Mother/Legal Guardian Name: *

Primary Parent Cell Phone (To serve as emergency contact): *

Secondary Parent Cell Phone:

GENERAL CONSENT:

I/we am the parent(s) or legal guardian(s) of this participant, and hereby grant my/our permission for him/her to participate fully in The Crossing's Power Kidz Club, and hereby give my/our permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.

Yes (This serves as my/our signature for General Ministry Consent)

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MEDICAL RELEASE:

I/we authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general and special supervision and on the advice of any physician or dentist 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. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. *

Yes

Hospital Insurance *

Yes

Insurance Company: *

Policy Number: *

Physician: *

Physician Phone Number: *

List any allergies or special medical problems your child may have: *

Parent with Primary Physical Custody or Legal Guardian: *

I/we authorize medical care for the student named above.

I/we DO NOT authorize medical care for the student named above.

PHOTOGRAPHIC RELEASE:

I/we consent to having our students' picture/video taken. *

Yes

I/we further consent to permit the Church to use the photos to be exhibited, portrayed or publicized by the Church in promotional, congregational, advertising or other material that the Church reasonably believes will assist the Church in its religious and congregational activities. I/we understand that the photographs may be displayed in digital, print or other formats, in the form of still photographs, motion pictures or videos, transparencies, television or other similar media. They further understand that the photos will not be used in connection with any profit-making activity. I/we the parent, on our own behalf and on behalf of said student, hereby releases the Church and its agents from any and all claims for damages for libel, slander, invasion of privacy or any other claim based on use of the above-described materials. I/we shall be entitled at no charge to a copy of any photo or video made of my/our child by the Church. *

Yes

LIABILITY RELEASE:

Release of All Claims

Furthermore, I/we (and on behalf of my/our child-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. *

Yes

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. *

Yes

FINAL SIGNATURES:

Name of Participant/Student: *

Name of Parent/Legal Guardian: *

I (the parent) have read the foregoing and understand the rules of conduct for participant. *

By checking this box, I verify this as my (parent) signature.

Required

Send me a copy of my responses.

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