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    PRC Student - Oct-Dec 2011

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    mhoffmsc
    This document is a permission, release, and consent form for a student to participate in student life events at Mountain Springs Church from October 1, 2011 through December 31, 2011. It collects information about the student such as name, address, emergency contacts, medical issues or allergies, and insurance information. The parent or guardian gives permission for the student's participation, acknowledges the student is physically fit, and releases the church from liability for any injuries or illnesses during activities. In the event of an emergency, the form authorizes the student life pastor or leader to consent to medical care and for the parent's insurance to be primary for any costs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    PRC Student - Oct-Dec 2011

    Uploaded by

    mhoffmsc
    18 views1 page
    This document is a permission, release, and consent form for a student to participate in student life events at Mountain Springs Church from October 1, 2011 through December 31, 2011. It collects information about the student such as name, address, emergency contacts, medical issues or allergies, and insurance information. The parent or guardian gives permission for the student's participation, acknowledges the student is physically fit, and releases the church from liability for any injuries or illnesses during activities. In the event of an emergency, the form authorizes the student life pastor or leader to consent to medical care and for the parent's insurance to be primary for any costs.

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    PRC Student_ Oct-Dec 2011

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    This document is a permission, release, and consent form for a student to participate in student life events at Mountain Springs Church from October 1, 2011 through December 31, 2011. It collects information about the student such as name, address, emergency contacts, medical issues or allergies, and insurance information. The parent or guardian gives permission for the student's participation, acknowledges the student is physically fit, and releases the church from liability for any injuries or illnesses during activities. In the event of an emergency, the form authorizes the student life pastor or leader to consent to medical care and for the parent's insurance to be primary for any costs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views1 page

    PRC Student - Oct-Dec 2011

    Uploaded by

    mhoffmsc
    This document is a permission, release, and consent form for a student to participate in student life events at Mountain Springs Church from October 1, 2011 through December 31, 2011. It collects information about the student such as name, address, emergency contacts, medical issues or allergies, and insurance information. The parent or guardian gives permission for the student's participation, acknowledges the student is physically fit, and releases the church from liability for any injuries or illnesses during activities. In the event of an emergency, the form authorizes the student life pastor or leader to consent to medical care and for the parent's insurance to be primary for any costs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    / NA

    Last, First Name: _______________________________

    PRCF OD11

    Permission, Release and Consent: Student Life Events


    Mountain Springs Church 7345 Adventure Way Colorado Springs, CO 80923
    This form will be kept on file at Mountain Springs Church for use From October 1, 2011 through December 31, 2011.
    NOTE:

    IF YOU ARE UNDER 18, A PARENT/LEGAL GUARDIAN MUST SIGN THIS DOCUMENT.

    PARTICIPANT INFORMATION Name: ___________________________________ Sex: Male


    Female

    Address: __________________________________________________________________________ Home Phone: ______________________________ Date of Birth (mm/dd/yyyy): ___________________ Parent(s) Name: ____________________________ Medical & Emergency Contact Information Emergency Contact Person: Emergency Contact Phone (Day / Evening): Medical problems or allergies: Medications taking: _________________________________________ _________________________________________ Cell Phone: _________________________ Grade as of Fall 2011: ________________ Parent Cell: _________________________

    Allergies/Medication? YES / NO

    ____________________________________________________ ____________________________________________________ Yes


    No

    Is the student covered by personal/family medical insurance? Name of Insurance Company:

    If yes, the following information must be completed and a copy of the insurance card must be attached.

    ____________________________________________________ Group/Subscriber Number: ___________________

    Policy Number: _____________________

    Insurance Phone # and/or Claim Address: ________________________________________________ I hereby give my permission for my child to be involved in all Student Life scheduled activities from September through December 2011. I acknowledge that my child is physically fit to participate in these activities. I hereby release Mountain Springs Church and its staff and sponsors from responsibility and liability for any injury or illness that I/my child may sustain during any of the associated activities. In the event of an emergency, I hereby authorize Chris Fetters, MSCs Student Life Pastor, or a Student Life adult leader or sponsor as an agent for me to consent to any x-ray examination, medical, dental or surgical diagnoses and to a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where services are rendered, either at a doctors office or in any hospital. I expect to be contacted as soon as possible. I realize that my health insurance and/or I will be responsible for payment for any medical services rendered. Further, as parent or legal guardian I am responsible for the health care decisions for my child and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child. Any policy of the church or organization sponsoring this event will be used as the secondary coverage. _____________________________________________ Signature of Participant or Parent/Guardian
    (parent/guardian must sign if participant is under age 18)

    Insurance Card Attached? YES / NO

    _______________________ Date

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