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    Schlitterbahn Medical Release

    Uploaded by

    Monica Cooper
    HERE YOU GO ANTHEM STUDENTS INTERNS FOR TOMORROW

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Schlitterbahn Medical Release

    Uploaded by

    Monica Cooper
    15 views1 page
    HERE YOU GO ANTHEM STUDENTS INTERNS FOR TOMORROW

    Copyright

    © Attribution Non-Commercial (BY-NC)

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    DOC, PDF, TXT or read online from Scribd

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    HERE YOU GO ANTHEM STUDENTS INTERNS FOR TOMORROW

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    15 views1 page

    Schlitterbahn Medical Release

    Uploaded by

    Monica Cooper
    HERE YOU GO ANTHEM STUDENTS INTERNS FOR TOMORROW

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    Grace Community Church

    INTERN OUTING TO SHLITTERBAHN


    Grace Community Church
    14505 Gulf Freeway
    Houston, TX 77034
    Registration and Medical Release

    (Please print and complete)

    :: CHILD INFORMATION
    Last Name _______________________________________
    Address _________________________________________
    Grade (as of fall 2012) _____ Male _____ Female _____
    Email ___________________________________________
    Parent/Guardian __________________________________

    First Name _______________________________________


    City ____________________ State ____ Zip ________
    Birth Date ____/_____/_____ Age _____
    Phone __________________________________________
    Phone __________________________________________

    :: MEDICAL INFORMATION (If you do not carry insurance, please write N/A for Medical Insurance)
    Medical Insurance ________________________________
    Policy # _________________________________________
    Family Physician _________________________________
    Phone Number ____________________________________
    Allergies ___________________________________________________________________________________________
    Medical Conditions ___________________________________________________________________________________
    Have You had a Tetanus shot in the last 12 months? Yes ____ No ____
    :: MEDICAL RELEASE
    I give the health care providers of the trip/event permission to give over the counter medication and administer other
    treatment as deemed necessary. Please attach any other additional medical information.
    List any exceptions below:
    ___________________________________________________________________________________________________
    ___________________________________________________________________________________________________
    :: LIABILITY RELEASE
    For participation in a Grace Community Church trip/event, we (I) as legal guardian(s) of the participant, hereby grant my
    (our) permission to take the participant to a doctor or hospital, and authorize medical treatment, including emergency surgery
    and medical treatment. Furthermore, I (we) assume all responsibility of all medical bills and all charges.
    I (we), release Grace Community Church and its staff, directors, and/or volunteers from all liability for personal injury,
    sickness, death, and/or property damage of any nature that occur during this trip/event. I (we) also assume all risk and
    expenses as a result of participation.
    Should it be necessary for the participant to be returned home for medical reasons, disciplinary action, or other wise, I (we)
    will assume all transportation cost.
    :: ADVERTISEMENT RELEASE
    Any media obtained by Authorized GCC Staff may be used for future promotional use without any compensation or prior
    approval.

    Signature of Parent/Guardian ____________________________________________________

    Date ____ /____ /____

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