EmailMe Form - C3 Medical & Liability Release

Student Information

Student Name *

First Last

Student Gender *

Student Birthdate *

MM / DD / YYYY

Grade of during the 2019-2020 School Year *

Student Phone (if Student has a phone)

### - ### - ####

Student T-Shirt Size *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian Information

Parent/Guardian 1 Name *

First Last

Parent/Guardian 1 Phone *

### - ### - ####

Parent/Guardian 1 Email *

Parent/Guardian 2 Name

First Last

Parent/Guardian 2 Phone

### - ### - ####

Parent/Guardian 2 Email

Additional Emergency Contact

Additional Emergency Contact Name *

First Last

Additional Emergency Contact Relationship *

Additional Emergency Contact Phone *

### - ### - ####

Medical Information

Insurance Company *

Primary Named Insured on Policy *

Group/Policy Number

Physician

Allergies *

Prescriptions Currently Taking:

	Prescription Name	Dosage	Instructions
Prescription #1
Prescription #2
Prescription #3

Any Additional Medical Notes

Over the Counter Consent

I give permission for a member on staff at Carterville Christian Church (C3) to provide over the counter medications to the named participants above per necessity only, unless otherwise previously stated in allergies or medical alerts.

Signature *

Clear

Parental/Legal Guardian Consent

As the parent or legal guardian of the above named minor, I give my permission for him or her to participate in activities, events and programs with Carterville Christian Church (C3). I understand the inherent risks that are involved in these activities and hereby release C3, its staff, employees and these activities, events and programs. Further, I do authorize the minister, adult, leader, or sponsor of the activity, event, or program, in the event I cannot be reached by phone, to give consent to a physician and or hospital for emergency medical or surgical treatment. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment. Further, I authorize C3 to use photographs and video footage of the participant.

Signature *

Clear