Yearly Medical & Media Release

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This form is valid for all church-sponsored youth/children's activities

Student's Name *

Date of Birth *

Parent/Guardian Name *

Address *

Best phone number to be reached at. *

Optional second phone number (work, cell, etc.)

Emergency Contact (other than above) Name and Relationship to child *

Emergency Contact Phone Number *

Optional Second Emergency Contact (other than above) Name and Relationship to child

Optional Second Emergency Contact Phone Number

Insurance Company *

Name of Policy Holder *

Policy Number *

Family Physician

Family Physician Phone Number

Food Allergies *

Penicillin or Drug Reactions *

Ongoing Medications (list instructions) *

Please list any other health info we should know (allergies, physical limitations or any other concerns we should be aware of): *

MEDIA RELEASE: I, the legal parent/guardian of my child listed above, hereby authorize and consent to the use of images or videos of my child, with or without their name, by New Life Assembly of God of Ellendale, ND for purposes including but not limited to: promotional materials, printed publications, internet posts including social media, television, and other media sources. I do this with full knowledge and consent and waive all claims for compensation for use or for damages. I release New Life Assembly of God, its officers, trustees, employees, and agents from liability for any claims by me or any third party in connection with the use of the image of my child listed above. *

Yes

By entering your name below, you are effectively providing your signature, indicating the following: *

I, the undersigned, being the parent or legal guardian of the dependent named above, release New Life Assembly of God, its employees, and volunteer assistants from any liability whatsoever arising out of injury, sickness, or damage arising during the course of any church sponsored activity. I understand that I will be notified in the case of a medical emergency involving my child/youth. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my student is injured or becomes ill. I understand that the Church (New Life Assembly of God) will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as a parent/guardian.

I agree to notify the Church in the event of any health changes, which would restrict my child’s/youth’s participation in any normal activities.

Required

Parent/Guardian signature *

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