Medical Release Form Test

Medical Form Test

Knox Presbyterian Church
Youth Ministry Medical Authorization, Health History, and Youth Ministry Release for 2017/18
If Different.

By signing this Permission and Waiver Form, I expressly warrant that my child named above or I, if I am a participant, am capable of withstanding both the physical and mental demands of these activities. I also expressly assume all risks to the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release Knox and its officers, ministers, leaders, employees, volunteers and agents from any claim that I or my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in these activities. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives or assigns may have against Knox or its officers, ministers, leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless Knox and its officers, ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of me or my child during such activities other than from the willful, wanton, or reckless misconduct of Knox staff or volunteers.

I further agree to allow all photographs, video and/or any digital images of my child or me reproduced in association with Knox to be used in any way by Knox, and release all claim to rights in and to those images and waive any and all rights to compensation and / or royalties, etc. for the use of any such images of me or my child. I permit Knox or other Released Parties to re-use , publish, and republish photographs or video and digital pictures of my child or me and in which my child or I may be included, in whole or in part, or composite or distorted in character or form, without restriction.

I understand that participating in programs, recreation and other activities of Knox Evangelical Presbyterian Church (Knox) is a privilege. Prior to my or my child’s participation in such activities, I acknowledge that there are certain risks associated with these activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

I authorize Knox employees/volunteers to give my child over the counter non-prescription medicine should the need arise (including, but not limited to, aspirin/Tylenol, Pepto-Bismol, cough drops, etc.)

I recognize that there may be occasions where the child named above or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of Knox to seek and secure any needed medical attention or treatment for the child named above or me, if I am a participant, including hospitalization, if in the agent’s opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.

Please list any important medical information (including restrictions or infectious diseases) for our staff to be aware of for your child.
Please list any important allergy information staff needs to be aware of (especially food allergies).
Please list any necessary medications for your child.
Health Insurance Information

I represent that I am the parent/guardian of the child listed above, who is under 18 years of age. I have read the above information and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of Knox, including any special events/activities/trips. I understand that if my son/daughter is taking prescription medicine during an event, I will notify the leader in charge of the event/trip and will ensure that it is properly labeled in a sealed bag with dosage instructions. I agree to defend and indemnify Knox Presbyterian Church, its officers, ministers, leaders, employees, volunteers and agents against any claim or action that might arise on behalf of myself or my son/daughter other than for the willful, wanton or reckless misconduct of Knox Presbyterian Church, its employees or volunteers. I hereby consent to the Medical Authorization, Health History, and Youth Ministry Release Form, including the Release of Liability and photo release above, on behalf of the child, and agree that this Medical Authorization, Health History, and Youth Ministry Release Form shall be binding upon me and my estate. I also agree that if my child breaks the Youth agreement, he or she is subject to be sent home at the parent’s expense before the event is over. The Youth’s participation in an activity, trip, etc. will act as their agreement of the Youth Agreement below.

I desire to participate in Knox 2017/18 events knowing that I will be exposed to spiritual things and will get to know other participants. I promise to obey the instructions of the adult leaders. I promise to respect God, respect myself, respect other people, and respect property. I understand that my agreement holds me responsible to these things and the consequences thereof. I agree to participate in these activities of Knox. My participation in Knox activities depends on my support of this agreement. By signing this agreement, I understand that action may be taken and I am subject to be sent home if I partake in any of the following activities: possession of illegal drugs, medication not prescribed to me, alcohol or tobacco products, possession of weapons, disrespect for authority, or any other activity that adult leaders deem as inappropriate.