Youth Medical Release Form - Garden Valley Church

Birthdate *

Gender *

Phone number *

Grade *

School *

Medical Insurance Company *

Group Number *

Policy Number *

Household members

Primary Care Doctor *

Doctor's Office Phone Number *

Medical History

Please answer the below questions and give details as needed, feel free to include as much detail as possible in the case of emergency or need, including what (if any) action is necessary for the protection. Please include any names of medications, even if your youth maintains and monitors on their own.

For your child's safety and our knowledge, is your student a: *

Good Swimmer

Fair Swimmer

Non-Swimmer

List any allergies to food, drugs, pollens, insect bites, etc *

If this does not apply, please write "Not Applicable".

Does your child suffer from, or has ever experienced, or is being treated for the following:

asthma

epilepsy / seizure disorder

heart trouble

diabetes

frequent upset stomach

physical handicap

Date of the last tetanus shot *

Does your child wear

glasses

contacts

Can your child be given pain reducing medication (Tylenol, aspirin, excedrin, etc) as deemed necessary? *

Yes

No

Please list any current medication, health problems, or limitations below.

Acknowledgement and Authorization

Students are under the authority of Garden Valley Church staff and volunteers. It is necessary to respect one another, staff, adult leaders, property, and respect and comply with the event schedules. Participation is expected in all groups and activities. Students are expected to not steal, participate in illegal drugs, weapons, tobacco, fighting or alcohol. On overnight events, no members of the opposite sex are allowed in a room or tent together without supervision. No offensive or immodest clothing. No inappropriate music, videos, games, websites, texting, etc. No pranks or wandering off alone. No students may drive. Students who damage property are responsible to pay for repair/replacement. Parents may be asked to drive and pick up student if rules are violated. Continued or serious misconduct may result in exclusion from outside youth events for up to one year.

By signing this, I agree that I am the guardian of the above named child, a minor. I recognize the activities involve a certain level of risk in both transportation and the activity while there. However, I wish for my child to participate despite the risk and wish to assume the risk and liability myself, to the extent that damages are not covered by the church liability insurance. I also released Garden Valley Church, its church staff and volunteer leaders from any liability arising out of disregarded rules, property damage, or loss resulting in any injury, sickness, or death that may be sustained by my child as a result of participate in any GVC activity.
As the legal guardian of the above named child, I understand that if my child misbehaves and violates the GVC rules, I may be called to pick them up from any activity. Therefore, I hereby waive and release GVC, its staff, and all persons organizing and participating in the activity from all uninsured liability for any injury to my child while participating in church activities.
In the event of a medical emergency, I hereby authorize the supervisor and/or leadership of GVC to authorize such medical treatment for my child as he or she may deem necessary and appropriate. I take full responsibility for medical expenses incurred for my child and indemnify the church of all costs of this medical treatment.
We have read the rules of conduct, the above evaluation of health, and permission to participate in youth group activities for the period of one year from the date of signature. We, the parents and the youth, agree to abide by the stated personal limitations and code of conduct.

Student Electronic Signature *

Please write name

Date Electronically Signed *

Parent Electronic Signature *

Please write name

Date Electronically Signed *