Central California District, PCG Inc. 2019 TEEN EXTREME LOCK-IN MEDICAL RELEASE FORM. Continued
MEDICAL RELEASE (to be filled out by Parent/Guardian)
I HEREBY AUTHORIZE THE CENTRAL CAL YOUTH MIN. AND/OR ITS REPRESENTATIVE, AS AGENT FOR MYSELF TO PROCURE MEDICAL, HOSPITAL OR DENTAL CARE FOR MY CHILD NAMED ON THIS FORM, IN THE EVENT OF INJURY OR ILLNESS WHILE THE CHILDIS IN THE CARE OF THE ABOVE NAMED, I UNDERSTAND THAT I AM FINANCIALLY
RESPONSIBLE FOR ANY CARE PROCURED. IT IS UNDERSTOOD THAT THIS AUTHORIZATION IS GIVEN IN ADVANCE OF ANY SPECIFIC DIAGNOSIS, TREATMENT, OR HOSPITAL CARE BEING REQUIRED. BUT IS GIVEN TO PROVED AUTHORITY ON THE PART OF MY AGENT TO CONSENT TO SUCH MEDICAL CARE, SHOULD IT BECOME NECESSARY. I ALSO AUTHORIZE DESIGNATED MEDICAL PROFESSIONALS TO DISPENSE OVER THE COUNTER MEDICATIONS AS NEEDED TO THE STUDENT LISTED ABOVE. I HEREBY IRREVOCABLY CONSENT TO AND AUTHORIZE THE UNRESTRICTED USE AND REPRODUCTION BY YOU OR ANYONE AUTHORIZED BY YOU, OF ANY AND ALL PHOTOGRAPHS AND/OR VIDEO IMAGES WHICH YOU HAVE TAKEN OF THE STUDENT LISTED ABOVE, FOR USE WITHIN THE SCOPE OF THE CENTRAL CALIFORNIA YOUTH MINISTRIES, PENTECOSTAL CHURCH OF GOD, INC.
After having read, or have had read to me, I agree to abide by the rules and regulations of the event and to waive any and all claims against the District Organization, The Pentecostal Church of God, or any of its District Board or its representatives, because of any injury or other damage that may be incurred to me or my property in connection with,
or incident to, the Pentecostal Church of God. I also give my permission for any pictures taken maybe used for Central Cal Youth Ministries.
