Cedar Valley-Nauvoo Mission Center YOUTH Discipline, Liability, Medical & Photo Release form.
Email address *
participant or staff *
Name of Event: (Click all that apply) *
School grade completed at time of activity *
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Participant's Name: *
Your answer
Sex: *
Required
Age: *
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Date of Birth: *
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YYYY
Street Address: *
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City: *
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State: *
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Zip code: *
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Participant email address
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Parent/Legal Guardian Name: *
Your answer
Relationship to Participant: *
Your answer
Cell Phone: *
Your answer
alt Phone:
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Work Phone:
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Person(s) allowed to pick up participant from event: *
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In case of an emergency, and Parent/legal guardian cannot be reached, please contact
Contact 1 Name: *
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Contact 1 phone: *
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Contact 1 relationship: *
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Contact 2 Name: *
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Contact 2 phone: *
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Contact 2 relationship: *
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MEDICAL INFORMATION
Insurance Carrier: *
Your answer
Policy #: *
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Participant's Physician: *
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Phone: *
Your answer
Date of last tetanus shot: *
Your answer
Allergies: *
Your answer
Medication(s) & Dose(s) *
Your answer
List any specific information that the event director or staff should know about the participant's health:
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PERMISSION FOR MEDICAL TREATMENT
I, the parent/legal guardian, do hereby authorize the event director/staff, in the event that I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while at this event or any associated off-site events. *
Required
PHOTO RELEASE
I, the parent/legal guardian, do hereby give my consent and authorize Community of Christ, its successors,heirs, legal representatives, assigns, and agents to use and reproduce the participant’s name, voice and/or likeness (photographic, illustrative, audio or video tape, film or electronic and/or digital image), and circulate and use the same for any and all official resources, use, or purpose including but not limited to print, film, or electronic media and reproduction or digital representation of every description on the Internet/World-Wide Web. Consideration is hereby waived in perpetuity, and no further claim of any nature whatsoever shall be made by me, my heirs or assigns. Community of Christ has made no representations concerning the use here of to me. *
Required
CONSENT AND LIABILITY RELEASE:
I, the parent/legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in this event and any associated off-site events. The participant identified on this form and I, the parent/legal guardian, understand that all participants are expected to abide by the event rules and be directly responsible to the event director/staff. The event director/staff assume responsibility for discipline at the event and, if necessary, may, because of misconduct or disobedience, require the participant to leave. In such an instance, I, the parent/legal guardian, will assume full responsibility for returning the participant to his/her home.I, the parent/legal guardian, acknowledge and am aware that this event may involve hazards and risks,including those associated with the transportation of the participant to any activities (on-site and/or off-site)and back, which I am prepared to accept on behalf of the participant. Accordingly, as part of my decision to allow the participant to attend this event and all associated activities, I hereby release Community of Christ(including its officers, employees, agents, assigns, and affiliates) from any and all liabilities with the respect to Injury, sickness, disease, death, or damage as a result of participation in this event and all associated activities. This release applies to any and all liabilities to me, the participant, either of our estates of any type or description, whether arising from ordinary negligence or otherwise, and whether involving fees and expenses of any kind.Further, I, the parent/legal guardian, understand that the participant may receive a physical examination upon arrival at the event. My consent and e-signature, as parent/legal guardian, are given below. I have read and agree to the information given in its entirety on this form. BY ENTERING YOUR NAME IN THE BOX BELOW, YOU ARE EFFECTIVELY PROVIDING YOUR SIGNATURE, INDICATING THAT ALL THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE, TO THE BEST OF YOUR KNOWLEDGE, AS WELL AS, CONFIRMING YOUR ANSWERS FOR "CONSENT FOR MEDICAL RELEASE" AND "PHOTO RELEASE" *
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Community of Christ/Cedar Valley-Nauvoo Mission Center cannot allow anyone to attend events/activities without completing and submitting this form!
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