Emergency Information and Release Form
Valid for one year from date submitted
Email address *
Name of Student *
Your answer
Parents' Names *
Your answer
Grade *
Required
Address *
Your answer
Phone Number *
Your answer
Insurance Company *
Your answer
Emergency number we can reach a parent at *
Your answer
Emergency Contact and number if we cannot reach parent *
Your answer
Please list any allergies or medical restrictions
Your answer
Date of last tetanus shot
MM
/
DD
/
YYYY
By Writing in my name below I authorize my son or daughter to go on church sponsored trips and have fully completed the Emergency Information and Release Form. I acknowledge that my son/daughter will be participating in BCC day trips or activities sponsored by Beavercreek Christian Church (the "Church" or "BCC"). The parents/guardians and above named student release from all actions, claims, and demands against the Church by reasons of my child's participation in BCC activities and agree that he/she shall indemnify and hold harmless the Church against any and all losses, claims or damages of the parent of child arising out of, or resulting from a BCC sponsored activity. *
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A copy of your responses will be emailed to the address you provided.
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