Spokane Bethel Kids Medical Release Form 2019
This form is required for children to participate in Kids Events.
Bethel Church of the Nazarene
1111 S. Thor Spokane, WA 99202
(509) 534-7751
Email address *
Student's Full Name *
Your answer
Address (Street, City, State, Zip) *
Your answer
Student Birthdate *
MM
/
DD
/
YYYY
Legal Guardian(s) Full Name *
Your answer
Parent/ Legal Guardian Phone Number(s). Example: Home: (509) 555-5555 Cell: (509) 444-4444 *
Your answer
Parent/Legal Guardian Email
Your answer
Emergency Contact Person *
Your answer
Emergency Contact Person Phone # *
Your answer
Local Physician
Your answer
Physician Address
Your answer
Physician Phone #
Your answer
Health Insurance Provider/Company *
Your answer
Health Insurance Phone #
Your answer
Policy Number *
Your answer
We/I the undersigned participant/parent/guardian grant permission for the participant to participate in any activity sponsored by Bethel Church of the Nazarene from January 1, 2019 through December 31, 2019. We have been advised of the nature and extent of the activities that may take place, and we/I represent to you that the participant is physically and mentally able to participate in those activities. We understand that an activity might present the risk of injury or death, and hold you, your agents, employees, and representatives harmless from any liability for injury or death to the participant while engaged in any activity which is caused or contributed to by the conduct of the participant, and agree to indemnify and defend you against any claim or liability asserted against you for any such injury or death to the participant. We also hold you, your agents, employees, and representatives harmless from any and all liability to any other person or entity arising as a result of the conduct of the participant in this activity and agree to defend and indemnify you, your agents, employees, and representatives against any claim or liability arising as a result of such conduct. If we are not personally present at these activities in which the participant is to participate, so as to be consulted in the case of necessity, you are authorized on our behalf to arrange for such medical, hospitalization, and/or surgical treatment as you may deem advisable by a licensed physician for the health and well-being of the participant. By signing below I also give permission to leaders/staff members to dispense over-the-counter medication to my child (i.e., tylenol, cough drops, cough syrup, antibiotic ointment, etc.). *
Required
Legal Guardian Initials for the above waiver: *
Your answer
Please list any medical allergies, medications being taken, medical problems, or other pertinent information: (if none, put N/A) *
Your answer
I give permission for my kid(s) to have their pictures taken to be used on church bulletin boards, slide shows, church website, and in slide shows shown to the church *
Bethel desires to keep minors safe in all circumstances, including transport between church and Bethel Kids activities. We will make efforts to have two adults when transporting children. But this is not always possible. There may even be times where one adult will need to transport one child. By signing below, you acknowledge that we will make efforts to have two adults for transport and that you are giving permission for an authorized staff member or volunteer with Bethel to transport your child without another adult present. I give permission for my kid(s) to be transported by one adult volunteer or paid staff. *
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