Discipline Liability And Medical Release Form printable pdf download

First Christian Church of Johnson City, TN

Discipline, Liability and Medical Release Form

Valid: ___/20___ thru ___/20___

year

Participant Name: _____________________________________________________

□ Male □ Female

Current Grade: ______

Birth date: _______________________

Home Phone: ____________________

Parent Cell Phone: _______________

Cell Phone Provider: ____________________ Do you accept text messages? Yes No

Parent Email: _________________________________________________________

Student Physical Address: ________________________________________________

City:____________________________ State: _______ Zip:_____________________

Parent’s/Legal Guardian’s name(s) (residential custody):

______________________________

__________________________________

Signature(s): _____________________

__________________________________

Emergency Contact if parent/Legal Guardian can’t be reached:

Name: ____________________________ Relationship:

_________________________

Phone: ___________________________

Home Church of Participant (if other than FCC):_______________________________

Insurance Company Name:______________________________________________

Policy Number:_________________________________________________________

Physician’s Name and Telephone:__________________________________________

List any known allergies (medication or otherwise):_____________________________

_____________________________________________________________________________

Medications currently taking: ______________________________________________

_____________________________________________________________________

*********************PLEASE ATTACH COPY OF INSURANCE CARD*********************

In consideration for being accepted by FIRST CHRISTIAN CHURCH of Johnson

City, TN for participation in any activities or events sponsored by First Christian Church

during the school or calendar year noted in the heading above, I being 18 years of age

or older, HEREBY RELEASE, FOREVER DISCHARGE, AGREE NOT TO SUE, AND

AGREE TO HOLD HARMLESS FIRST CHRISTIAN CHURCH and its staff, Board,

employees or agents thereof, from any and all liability, claims, demands or judgments

for personal injury, sickness, death, as well as property damage and any expenses of

any nature whatsoever which may be incurred by me and/or my child while participating

in any activity or event with First Christian Church of Johnson City, Tennessee during

the calendar year above.

By my or my child’s participation in any such First Christian Church activity or event

during the calendar year indicated above, I acknowledge that the participant (including

my child) has my permission to participate and I agree that this Release shall be valid

First Christian Church - 200 East Mountcastle Drive - Johnson City, TN 37601 - 423.232.5700

Discipline Liability And Medical Release Form

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