Please Print clearly

Student Name: _____________________________ Grade: ____

Address: _____________________________
City: _________________________________ Zip: _______

Home Phone: (_____) ______________________

Parent/Guardian Name(s): __________________ , __________________

Cell phone #s: ______________________ , ______________________

(Student’s name goes here)

___________________________ has the permission of the undersigned to participate in the following described event:

___________________________________ Event Name

Date of Event: ___ /___/___.

In the event of an emergency affecting the heath or welfare of this participant, the sponsors, leaders, or adult chaperones have permission to administer first aid and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be borne by the parents or guardians of the participant. Insurance afforded by NorthCreek Church of Walnut Creek is an excess insurance, over any and all valid and collectable insurance coverage available to or for such person, as expressly named above.

Participant’s Health Insurance Carrier: __________________________________

Policy # _______________________

In the event that I/we can’t be reached…. an emergency call may be made to: __________________________ whose phone number is (____) ____-_______.

Signature of Parent or Guardian: ________________________________

Date: ___ / ___ / ___ (signature required)

Student’s Medical Update
Date of Birth: ___ / ___ / ___

Date of last Tetanus injection: ___ / ___ /___

Current Medications: ________________________________________________

Allergies: _________________________________________________________

Any Special medical instructions: ______________________________________

_________________________________________________________________

_________________________________________________________________

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