MCC Medical Release
Each student and adult must fill out the information below completely. Valid for one year from date signed
Email address *
Student's Name *
Your answer
Gender *
Date of Birth *
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DD
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YYYY
Grade *
Address *
Your answer
City/State/Zip *
Your answer
Student's Email Address *
Your answer
Parent/Guardian Name *
Your answer
Phone Number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Insurance Carrier *
Your answer
Policy Number *
Your answer
Name on Insurance Card *
Your answer
Physician's Name *
Your answer
Physician's Phone *
Your answer
Allegries/Medication *
Your answer
I hereby give my permission for myself or my child to participate in an activity organized by Miamisburg Christian Church. I hereby release, hold harmless and absolve Miamisburg Christian Church, their staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Miamisburg Christian Church staff or any adult counselor acting on behalf of Miamisburg Christian Church with respect to the activity, 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 (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child’s medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that Miamisburg Christian Church may tape or photograph my child and record his or her voice during their participation in the activity. I agree that Miamisburg Christian Church will be able to use them, in whole or in part, whether in original or modified form in any manner or media, including without limitation, for the purpose of advertising, promoting, and publicizing Miamisburg Christian Church, whether during the activity or thereafter. I hereby release and discharge Miamisburg Christian Church and all affiliated entities from any and all claims, demands, or causes of action that I have in connection with the use and exercise of the rights granted in this release. (Parent/Guardian Name & Date below) *
Your answer
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Miamisburg Christian Church. Report Abuse - Terms of Service - Additional Terms