FUSION Teens release/permission forms

 

 

 

 

 

 

FUSION MEDICAL/LIABILITY RELEASE  FORM

(ALL WHO HAVEN'T EVER FILLED OUT AND RETURNED MUST DO SO. CHECK WITH PASTOR IF NOT SURE)

 

MEDICAL RELEASE

Name______________________________________ Birthday______ /_______ /_______ Male  Female 

Parent/Guardian_________________________Phone (H)_______________Phone (W)_____________Phone (Cell)____________

Address_______________________________________________City ___________________ State_______ Zip______________

Second Parent__________________________Phone (H)________________Phone (W)_____________Phone (Cell)____________

Alt. Emergency Contact___________________Phone (H)_______________Phone (W)________________Phone (Cell)_________

Student email address __________________________________________Parent email address_____________________________

Medical insurance carrier _______________________________________Policy or group #________________________________

Carrier address________________________________________________Name of insured person__________________________

Name of family physician__________________________________________________Phone _____________________________

 

Health History (Check. Give approximate dates)                                                                      Allergies (dates not needed)

_______Frequent Ear Infections             _______Diabetes    _______Bleeding Disorders              _____Hay Fever

______Heart Defect/Disease            ______Asthma    _______Mononucleosis                    _____Poison Ivy

______Seizures                                   ______ADHD      _______Downs Syn.                          _____Penicillin

______Chicken Pox                           ______Measles   _______Mumps                                  _____Insect Stings

                                                                                                                                                                _____Drugs(specify)_________________

Chronic or recurring illness or medical condition___________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________

Dietary restrictions__________________________________________________________________________________________

 

Current medications (List both prescription, OTC & herbal)

Medication name: _______________________________ Dosage _________________Reason for taking_____________________

Medication name: _______________________________ Dosage _________________Reason for taking_____________________

Blood type (if known)_____________ Are all immunizations current? (MMR, tetanus, hepatitus) Yes      No

Describe your swimming ability: Beginner                   Intermediate      Advanced

Any other information you feel the leaders should know in advance about your healtht.____________________________________

__________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 LIABILITY RELEASE

 

I(We) acknowledge that my child's participation in the Cedar Creek Church youth program is voluntary and

may require involvement in activities that require traveling or physical exertion. Such activities may include,

but are not limited to: outings, athletic games, local excursions, and meetings. I (We) acknowledge that my

child's participation in any Cedar Creek  youth activity presents risks that my child may suffer property

damage, bodily injury, or death. Therefore, in consideration of my child's being allowed to participate in the

Cedar Creek  youth program activities, I (we) agree to the following:

 

Cedar Creek Church is not responsible for the loss or theft of personal belongings.

 

Misconduct may result in transportation home from an activity at parents' expense. A student dismissed for a

disciplinary reason will not receive a refund of the activity fee. (Continued next page)

 

 

I hereby take the following action for my child, myself, my executors, administrators, heir, next of kin, successors

and assigns: A) I waive, release, and discharge from any and all claims or liabilities for death or personal injury

damages of any kind, which arise out of or relate to my child's participation in Cedar Creek's Youth activities,

the following person, or entities: Cedar Creek Church, it's Senior Pastor, youth pastor and any

volunteers and  representatives of any of the above except in the case of gross negligence on the part of Cedar Creek, Cedar Creek staff or Cedar Creek volunteers.

  I indemnify and hold harmless the person or entities mentioned above from any claims made or liabilities assessed

against them as a result of my child's actions.

 

The undersigned _______________(parent/guardian), the parent and natural guardian or legal guardian of

___________________ (minor's name) hereby executes this document for and on behalf of the minor named

herein. I agree to indemnify and hold harmless the person or entities mentioned above for any claims or liabilities

assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the

minor in the execution of the Waiver and Release.

 

I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care

facility to treat the minor named herein for the purpose of attempting to treat or relieve any injury received by said

minor. I authorize any such Medical Provider to perform all procedures deemed medically advisable in attempting

to treat or relieve any such injuries. I consent to the administration of anesthesia as deemed advisable. I realize and

appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I

assume any such risk for and on behalf of myself and said minor. I understand that attempts will be made to contact

me in the most expeditious way possible. Permission is also granted toCedar Creek Church  representative to provide

the needed emergency treatment to the student prior to his admission to a medical facility.

 

I hereby agree to the all the above Cedar Creek Church  Student Ministry Waiver and Release Form Liability conditions.

 

Child's Name___________________________________________________________________________

Parent(s)/Guardian Signature______________________________________________________________

Parent(s)/Guardian Phone ________________________________________________________________

Date_________________________________

 

 

 

  

ACTIVITY PERMISSION FORM

(ALL MUST FILL OUT AND RETURN)

THIS  SECTION MUST BE FILLED OUT FOR EACH FUSION/JUBILEE ACTIVITY & GIVEN TO  THE PASTOR OR  CEDAR CREEK ADULT WHO IS IN CHARGE OF ACTIVITY BEFORE THE TEEN BEING ALLOWED TO ATTEND

 

 My child has permission to attend_________________________________________ on ____________________________ (date).

. Note: If it is your desire to limit your child's participation in any event, please submit your wishes in writing to

Cedar Creek Church prior to that event.

 

Parent(s)/guardian Signature ___________________________________________________ Date_________________

Student's Signature__________________________________________________________ Date_________________

 

 

 

 

 

 

Sunday
Sunday morning service 10:00 AM

Cedar Creek Church
30 East Main Street
PO Box 224
Hayfield, MN 55940
507-477-2255
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