BLAST 2024 MEDICAL RELEASE FORM

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This form must be filled out for each student and adult by the start of the event.
Students cannot participate without a medical release form.

Local Church *

Please Check One *

Student

Adult

First Name *

Last Name *

Email *

Contact Number *

Street Address *

City

State *

Zip Code *

Date of Birth *

YYYY

Gender *

Female

Male

Parent/Guardian Name (Students Only) *

Parent/Guardian Number (Students Only) *

Emergency Contact Name *

Emergency Contact Number *

List any medications you will be taking at BLAST *

List anything you are allergic to *

List and describe any medical conditions (or relevant information) you may have in case of an emergency *

Physician Name *

Physician Number *

Do you have Health Insurance? *

Yes

Name of insured: *

Health Insurance Company: *

Health Insurance Group #: *

Health Insurance Policy # *

I, the legal guardian of the student this form is filled out for, authorize the leadership of District BLAST 2024 to care for the administration of general first aid treatment for any minor injuries received to my child during the event.If the injury sustained is life threatening, or in need of emergency treatment, I authorize the leadership of District BLAST 2024 or its representative to summon any and all professional emergency personnel to attend, transport, and treat my child.I understand that District BLAST 2022 will require my son/daughter to make choices and keep a schedule, and that he/she may not be under direct adult supervision at all times.I agree to release and hold harmless any staff and lay assistants of Nazarene Youth International Ministries, the General Church of the Nazarene, Heritage Nazarene Church, Mount Vernon Nazarene University, and/or District BLAST 2024 from any and all claims, suits, costs and actions, of any kinds whatsoever, arising from their exercise of the power granted by this authorization.This liability release is valid during District BLAST 2024, March 8-9. Please type your name below with today's date as indication that you have read and agree to this liability release. * *

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