Request edit access
JSCC Medical Release/Liability Waiver
I give my permission for my student to go with Jefferson Street Christian Church, Lincoln, IL on church sponsored activities.

I release Jefferson Street Christian Church and its staff and volunteer leaders from responsibility and liability for any injury or illness that my child may sustain during these activities.

IN CASE OF EMERGENCY, I hereby authorize an adult leader to act as an agent for me, to consent to any X-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist licensed to practice under the laws of the state or country where the services are rendered, either at a doctor's office or in any hospital.

I expect to be contacted as soon as possible and before hospitalization or surgery is administered (unless the injury or illness is life threatening).

I give my permission for the staff and/or volunteers of Jefferson Street Christian Church to administer medications such as an epipen, inhaler, etc to my child when emergency treatment is required. I will fully disclose information necessary for staff and volunteers to determine if and when emergency medications are to be administered.

All other, non-emergency medications will only be given during day trips and overnight events when parents are not present to administer. I understand that non-emergency medications will not be dispensed by staff or volunteers without written permission and instruction by parents, while under Jefferson Street Christian Church care. These non-emergency medications must be in prescription bottles, labeled and accompanied by instructions of dosage.

Email address *
Check below to accept the terms stated above: *
Required
Parent/Legal Guardian Full Name: *
Your answer
Parent/Legal Guardian email address: *
Your answer
Today's Date: *
MM
/
DD
/
YYYY
Next
Never submit passwords through Google Forms.
This form was created inside of Jefferson Street Christian Church. Report Abuse - Terms of Service