Bridgeway Student Ministries Medical Release and Waiver of Liability
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Student Name *
Your answer
Student Gender *
Required
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Grade *
What grade has your student just completed?
Parent/Guardian Name *
Primary Emergency Contact
Your answer
Primary Contact's Relationship to Student *
Your answer
Primary Contact's Cell Phone *
Cell Phone Number
Your answer
May we text you at this number? *
Do you consent to receive text messages from Bridgeway Student Ministries (BridgeStudents)
If so, who is your cell phone carrier
If you said yes to the above consent, we need this in order to text you.
Your answer
Primary Contact's Home Phone
Home Phone Number
Your answer
Secondary Emergency Contact Name
Your answer
Secondary Contact's Relationship to Student
Your answer
Secondary Contact's Cell Phone
Cell Phone Number
Your answer
Secondary Contact's Home Phone
Home Phone Number
Your answer
Insurance Company Name *
Your answer
Insurance Cardholder's Name *
Your answer
Cardholder's Relationship to Student *
Your answer
Insurance Company Group or ID # *
Your answer
Insurance Company Policy or ID # *
Your answer
Insurance Phone Number *
Your answer
Personal Medical Information:
Physician's Name
Your answer
Personal Medical Information:
Physician's Phone
Your answer
Please select that which applies. *
Please send a detailed email to shauntae.adams@bridgeway.cc if you answered that your child has special needs or dietary restrictions that could NOT be detailed in the following questions. Any information that you can give us ahead of time to better serve your child is greatly appreciated.
Required
Medical and Special Concerns (Asthma, Diabetes, Phobias, Allergies, etc. and/or Special Instructions) *
Ex: Allergic to certain meds, rare blood type, fear of heights, does not eat pork, etc.
Your answer
Please list any special needs *
Your answer
Will your child be bringing medication with them? *
Medical History
List all operations/serious injuries with dates that have occurred within the past five (5) years
Your answer
Participation and Liability Release *
In consideration for the opportunity to participate in Bridgeway Student Ministries (BSM) events, including but not limited to Youth Alive, Small Groups, special events, and/or weekend retreats, with Bridgeway Community Church in Columbia, Maryland, we (both legal parents/guardians) acknowledge and accept the risks of injury associated with participation in events involving recreation activities, bonfires, archery, rock climbing, sledding, snow tubing, and other activities related to participation in youth functions. We (both legal parents/guardians) acknowledge and accept the risks associated with transportation to and from these events. We (both legal parents/guardians) accept personal financial responsibility for any injury or other loss sustained during BSM events or during transportation to and from BSM events, as well as, for any medical treatment rendered to the participant that is authorized by Bridgeway Community Church Student Ministries’ staff or volunteers. Further, we, (both legal parents/guardians) release and promise to indemnify, defend, and hold harmless Bridgeway Community Church Student Ministries staff or volunteers for any injury arising directly or indirectly out of BSM events or transportation to and from BSM events, whether such injury arises out of negligence.
Required
Medical Treatment *
In consideration of the possibility of injuries occurring, in the event that we (both legal parents/guardians) or other listed contact persons cannot be reached, we (both parents / legal guardians) authorize Bridgeway Student Ministries/designee or staff to consent to necessary dental and/or medical treatment recommended by a medical professional. I hereby give permission to medical personnel selected by Bridgeway Student Ministries/designee or staff to order X-rays, routine tests, and treatment. I understand that if I do not have medical insurance, we (both parents/legal guardians), will be responsible for any medical expenses in the event of a sickness and/or injury. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company.
Required
Photo Release *
We (both legal parents/guardians), voluntarily grant license of the following to Bridgeway Community Church, on behalf of the minor child or children: use and storage of the name and image, by means of digital or film photography, video photography, audio recording or other documentation; use of any stored data including the name and image in printed publications of Bridgeway Community Church; use of any stored data including the name and image in electronic publications of Bridgeway Community Church; and/or use of any stored data including the name and image in any Web site created by or for Bridgeway Community Church for its sole benefit.
Required
Communicating with Minors *
Employees and Volunteers are prohibited from engaging in one-to-one communications with minors, including the use of text messages, email or social media platforms, unless written or electronic (email) parental consent has been obtained. Do you, the Parent(s) and/or Legal Guardian of the child whom you have completed this waiver for, give Bridgeway Employees and official vetted BridgeStudents Volunteers, permission to communicate with the/your child via text messages, email, or social media platforms for programmatic and mentoring purposes with the understanding that the content of the communications is consistent with the mission, vision, and values of Bridgeway Community Church.
Required
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