2018 ANNUAL GENERAL LIABILITY, MEDICAL AND SURGICAL WAIVER
GENERAL LIABILITY, MEDICAL AND SURGICAL WAIVER
Including Property Damage, Transportation for Disciplinary Reasons and Personal Property Searches
Waiver Statement *
I am the parent and/or legal guardian of the student listed below and hereby acknowledge that he/she is under my care, custody, and control. Acting as the parent or legal guardian, I retain full liability for any physical injury to my child which occurs during participation in any First Free Will Baptist Church of Ozark event or activity. Further I do hereby waive and release any and all claims against First Free Will Baptist Church of Ozark, its staff, representatives or sponsors, whether in contract or of personal injury, bodily injury, property damages, damages, losses and/or death that may arise as a result of my child(ren)’s participation in any First Free Will Baptist Church of Ozark event or activity. In the event there arises an emergency necessitating medical/surgical attention, I expressly grant my permission and consent to the First Free Will Baptist Church of Ozark staff, its representatives, and sponsors, to make such decisions and to perform such medical treatments and/or surgery upon my child listed above which may in the information given to them be necessary and proper under the circumstance. I, the undersigned parent and/or legal guardian of above mentioned child, do release, acquit, discharge, and covenant to indemnify and hold harmless First Free Will Baptist Church of Ozark or its representatives or the sponsors, from any and all actions, causes of actions, related risks and dangers, including damages, negligence, liabilities arising out of the treatment of any sickness or accident, and any financial responsibility for all medical treatment provided. I also assume financial responsibility for any damage my child may cause, and for providing transportation home should it become necessary for disciplinary reasons. I also give my permission to the First Free Will Baptist Church of Ozark staff, its representatives, and the adult sponsors and chaperones to search my child's personal belongings, including but not limited to all luggage, purses, and backpacks, if deemed necessary on rare occasion for security reasons.
PARENT'S Electronic Signature *
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Student's First Name *
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Student's Last Name *
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Birth Date *
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Current or Completed Grade *
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Address *
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City, State, ZIP *
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Parents' Names *
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Contact Phone Number *
Boy or Girl
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Parents' Email *
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Emergency Contact Person *
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Emergency Contact Number *
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Clinic Name *
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Clinic Phone *
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Family Physician *
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Preferred Local Hospital *
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Insurance Company *
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Policy # *
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Insurance Member's Name *
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Insurance Company Phone Number *
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Allergies *
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Medications being taken *
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Physical Handicaps of Special Conditions *
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I swear that everything listed above is correct to the best of my ability. *
Today's Date *
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