Medical Release Form 1General Release/Hold Harmless Agreement2Student Ministry Medical Release Student/Participant Name* First Last Gender* M F Student/Participant Date of Birth* Month Day Year Grade*9th10th11th12thGraduation Year*2019202020212022Small Group*9th Grade Girls9th Grade Guys10th Grade Girls10th Grade Guys11th Grade Girls11th Grade Guys12th Grade Girls A (Kate & Aubrey)12th Grade Girls B (Sharon & Suzanne)12th Grade GuysHome/Best Phone*Other PhoneThe undersigned or a member of the immediate family of the undersigned desires to participate in various programs, events, or activities (herein collectively referred to as "Activities") operated or sponsored by Journey Christian Church. The undersigned or a member of the immediate family of the undersigned further understands and acknowledges that the undersigned or a member of the immediate family of the undersigned may incur injury or bodily damage while participating in such Activities. The undersigned or a member of the immediate family of the undersigned further understands and acknowledges that Journey Christian Church will not allow the undersigned or a member of the immediate family of the undersigned to participate in such Activities without releasing and holding harmless Journey Christian Church. Further, the undersigned or a member of the immediate family of the undersigned requests Journey Christian Church to allow them to participate in activities and in consideration thereof agree to hereby release and forever discharge Journey Christian Church, their officers and their directors and their employees, their agents and any parties volunteering on behalf of Journey Christian Church, from all actions, claims, costs, expenses or damages of any kind growing out of or related to any activity of Journey Christian Church in which the undersigned or a member of the immediate family of the undersigned participates. The undersigned or a member of the immediate family of the undersigned further acknowledges that this is a full and complete release for all injuries and damages which the undersigned or a member of the immediate family of the undersigned may sustain as a result of the undersigned or a member of the immediate family of the undersigned's participation in any Journey Christian Church program.Parent/Guardian Signature*Use your mouse (or your touch screen if you are on a tablet) to sign your name in the box below. Reset signature Signature locked. Reset to sign again Today's Date* MM slash DD slash YYYY Relationship to Student/Participant* I, THE UNDERSIGNED, being the legal guardian of STUDENT/PARTICIPANT NAMED ABOVE, give my permission for him/her to attend Activities under the direction of Journey Christian Church. The undersigned, being a parent and/or legal guardian of the above minor, does hereby authorize the treatment of the above minor by a qualified and licensed medical doctor in the event of a medical emergency, which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed, while said minor is participating in the above event, including transportation to and from the event site. This authority is granted only after a reasonable attempt has been made to contact me.Parent/Guardian Name* First Last Parent/Guardian Signature*Use your mouse (or your touch screen if you are on a tablet) to sign your name in the box below. Reset signature Signature locked. Reset to sign again Today's Date* MM slash DD slash YYYY Specify Medical Allergies, Chronic Illnesses or other Medical Conditions:Medical Health Insurance Provider:* Policy #:* EmailThis field is for validation purposes and should be left unchanged. Δ
