Winterfest Medical Form
Medical Authorization for: WINTERFEST February 17 – 19, 2023
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Address (Street, City, State, Zip) *
Phone Number *
Email Address *
Grade (If Not Student, Select Adult) *
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PLEASE READ THE FOLLOWING
I (We) do hereby release and discharge the Northside Church of Christ, Randy Mitchell, all other attending
adults and authorized representatives and staff from liabilities for any personal injury or damage to property
that may occur on the premises or as a result of activities. Also, I authorize emergency medical treatment if
needed and release the Northside Church of Christ authorized representatives and staff from any liability
connected with medical treatment.

I understand that if my child’s behavior is deemed unacceptable by the staff I will be called and be responsible
for any charges incurred in sending my child home. I also acknowledge that by signing, I give permission for
any pictures with my child to be used on the Northside Church of Christ website
PARENT/ PARTICIPANT SIGNATURE- By typing your name here, you signify that you have read and agreed to the information given above. *
Emergency Contact:
Please complete the emergency contact info below. (If adult, please list one emergency contact)
Parents Names
Father's Phone
Mother's Phone
Alternate Emergency Contact and Their Phone Number
Emergency Medical Data
Please complete the Emergency Medical Data information below.
Student's Physician's Name
Location of Physician (City, State)
Physician's Phone
Please list any known medical conditions, allergies, or medications taken.
Insurance Information
My student (or “I am” if adult) is insured under the following primary health care plan:
Insurance Compony
Plan Name
Insurance Group number / name
Subscriber number / name
Thank you for submitting this information.
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