Adult Medical Release & Activity Permission 2017-2018
I, ______________________________, agree to participate in off-site trips with St. Paul’s Youth Group and Christian Formation classes. *
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I understand that some of these activities involve travel in privately owned vehicles driven by adult volunteers or parish employees. I do hereby hold harmless and release St. Paul’s Episcopal Church, Cary, and all adult volunteers and employees from any liability in the event of any accident, injury, or loss of personal property involving me during this activity. In the event of a medical emergency, I understand that every reasonable effort will be made to contact my spouse or emergency contact at the phone numbers listed below. In the event that I am unable to make arrangements for emergency medical treatment for myself, I authorize any adult volunteer or parish employee associated with the Christian Formation or Youth Group activity to consent to all necessary medical care in my absence. I also understand that payment for such services is my responsibility as the parent/legal guardian. Adult Signature and Date: *
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Phone and Alternate/Cell Phone: *
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Emergency Contact, Relationship, Phone: *
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Medical Insurance Company: *
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Contact for Authorization: *
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Policy Number: *
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Any allergies, Medical Conditions, Restrictions, Special Needs : *
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