EMERGENCY INFORMATION
(to be kept on file)
Supervising Sponsor: NorthCreek Church Impact—College/Career

Name  
Address  
City                         Zip 
Phone                     Your cell #  
Your email (printed clearly!)   
 
(Name) _____________________________ has the permission of the undersigned to participate in IMPACT activities. In the event of an emergency affecting the health 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 participant, parents or guardians of the participant. Insurance afforded by the NorthCreek Church of Walnut Creek is an excess insurance, over any and all valid and collectible insurance coverage available to or for such person, as expressly named above.

Participant’s health insurance carrier   
 
Policy # or Kaiser number   
 
An emergency call may be made to   

whose phone number is   

Signature of participant (if over 18)  

Signature of Parent or Guardian (if under 18)  
 
Date   

Birth date                                 Last Tetanus injection date  

Current medications   

Allergies   

Special medical instructions  

  
(If necessary, please attached page with detailed explanation.)

NorthCreek Church 2255 Ygnacio Valley Rd. #R, Walnut Creek, CA 94598
Church Office 925.210.9036
Print date 5.16.07