Medical and Liability Waiver

Submit a copy for each student attending a youth event. A new form must be submitted per event.

by Student Ministry on February 21, 2021

Please submit a copy for each student attending the event. A new form must be submitted per new event.

Medical and Liability Release Form

Name of Event:*

Start Date of Event*

End Date of Event*

Start and End date of the above mentioned event that this medical waiver is valid for.

Student Name:*

Birth Date:*

Height and Weight*

For proper medicinal dosages

Gender*

Male

Female

Medical Waiver

Please read carefully and check all boxes.

Medical Waiver*

I authorize and give my consent to PHEFC officials or designee’s to arrange for the above student's medical or surgical treatment. I understand that the above officials and or designee’s will ATTEMPT to contact us by phone BEFORE relying on this authorization.

Unless, the situation warrants it, under no circumstance will medical treatment of any kind be given without the student’s consent or direction.

Liability Waiver*

We further agree to hold Prairie Hill Evangelical Free Church (and or its designee’s) harmless in any liabilities resulting from any negligence or fault, whether active or passive. This release will not apply to willful or intentional recklessness.

I/We understand that there are inherent risks involved in any activity of this nature, and I/We hereby release Prairie Hill Evangelical Free Church, its designee’s and volunteers thereof from any and all liability for any injury, loss, or damage.

Name*

Parent(s) Signature*

Date Signed*

Address

Home Phone*( ) -

Work Phone*( ) -

Insurance Company*

Insurance Policy #*

Group #:*

Name of Policy Holder*

Emergency Contact

Name*

If Parent/Guardian are not available, please call person above

Phone #1*( ) -

Phone #2*( ) -

Relationship to Child*

Administer OTC*

Yes

I authorize PHEFC staff to administer over the counter medications appropriate to my child's symptoms/age/weight

Allergies/Medications:*

Does the camper have any allergies to food or medication? What is the reaction? Is medication used to treat the allergic reaction?:

Known diagnosed illnesses or issues:*

List any diagnosed illnesses or issues:

Treatment*

What medications, including doses, are used to treat the above? Any side effects of his/her medications?:

Are your child's immunizations up to date?*

Yes

Date of last Tetanus*

Please leave this field blank.

Medical and Liability Waiver

Submit a copy for each student attending a youth event. A new form must be submitted per event.

About the Author

Student Ministry