Bark River Bible Church Medical/Liability Release Form

Activity: All Programs/Activities Dates: January 2007-January 2008

Personal Information:

Parents or Guardians Names:_________________________________________________________________________

Family Address, City, & Zip: ________________________________________________________

Home Phone:___(___ )__________________________ Cell Phone:___(____)______________

Father’s Work:___(____)__________________________ Mother’s Work:___(____)___________

Emergency Contact Person:____________ ญญญ ______ Phone:___( _) __________

Emergency Contact Person:________________________ ___ Phone:___( _ )__________

Insurance Information:

Insurance Company: Policy #:

Hospital Preference: Group #:

Name of Doctor: Doctor’s Phone:

List any allergies, medication being taken, medical problems, or other pertinent information:

I understand that if medical intervention is needed for this child during this activity, every attempt will be made to consult the contact persons listed on this form. If, however, those persons cannot be reached, I give my permission to the activity leaders to secure the services of a licensed physician or surgeon to provide medical treatment, including anesthesia, that is deemed necessary for the well-being of this child. I understand that all reasonable safety precautions will be taken at all times by Bark River Bible Church and its staff during events, trips and activities. I also understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to release, forever discharge and hold harmless Bark River Bible Church, its leaders, employees and volunteer staff from any and all liability and claims for damages, losses, sickness or injury incurred by this child.

Parent or Guardian Signature:________________________________________Date:____________________