Medical Release Form printable pdf download

MEDICAL RELEASE FORM

(Release of all Claims)

While accompanying Mundelein Church of the Nazarene to:

______________________________________ (trip/activity) on ___________ (date)

I authorize __________________________________________ (name of minor child)

to receive medical and/or dental care in the event of a medical emergency/illness.

understand that abovementioned child will receive on-site first aid, however if additional aid

is deemed necessary by any chaperone appointed by the church, transportation to the nearest

medical facility will occur.

Signature ____________________________________ (parent/guardian of minor child)

Home Telephone Number ______________ Work/Cell Telephone Number ______________

Insurance Company/Telephone Number __________________________________________

Policy Number ________________ Responsible Party/SSN __________________________

Please list any known allergies or medical conditions:

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LIABILITY RELEASE FORM

(Release of all Claims)

While accompanying Mundelein Church of the Nazarene to:

______________________________________ (trip/activity) on ___________ (date)

I do hereby release, forever discharge, and agree to hold harmless the church and the

directors thereof from any and all liability, claims or demands for personal injury, sickness or

death, as well as property damage and expenses of any nature which may be incurred by the

undersigned/ participant occurring while said person is participating in the above-described

trip or activity. The undersigned further hereby agrees to hold harmless and indemnify said

Church, its directors, employees and agents for any liability sustained by said acts of said

participant, including expenses incurred attendant thereto.

Signed this _____ day of _________, 2008

Participant Signature _______________________________ (parent/guardian if minor child)

Participant Name __________________________________

Medical Release Form