Thrive Medical and Liability Release Form

Valid September 1, 2012 - August 31, 2013

Please fill in the following medical and liability release form for the 2012-2013 school year. This form is required for attendance at all activities with Thrive Student Ministry (Jamul Community Church)

STUDENT INFO
Student's First Name	*
Student's Last Name	*
Date of Birth	*	- - Choose One - - January February March April May June July August September October November December *- - Choose One - - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * ---- 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
Age	*
Current Grade	*	- - Choose One - - 12 11 10 9 8 7 6
Gender	*	Male Female
Address	*
City, State, Zipcode	*	*- - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY *
Home Phone (xxx-xxx-xxxx)
Cell Phone (xxx-xxx-xxxx)		Do not text
Cell Carrier		At&t Cricket Sprint/Nextel T-Mobile Verizon Other
E-mail
PARENT/GUARDIAN INFO
Parent/Guardian Name(s)	*
Cell Phone (xxx-xxx-xxxx)	*	Do not text
Cell Carrier		At&t Cricket Sprint/Nextel T-Mobile Verizon Other
Parent's e-mail	*
I would like to receive e-mails from Thrive Student Ministry with info on upcoming events
EMERGENCY CONTACT - in case above number does not answer, please notify:
Name	*
Relationship	*
Phone (xxx-xxx-xxxx)	*
Doctor
Phone (xxx-xxx-xxxx)
HEALTH HISTORY
Allergies	*	none insect stings/bites drugs food other
Other Conditions		Heart Condition Frequent Colds Chronic Asthma Diabetes Hay Fever Frequent Stomach Upsets Epilepsy Physical Handicap Other
If you ckecked any of the boxes above, please provide details/treatment
Date of last tetanus shot		- - - - 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Any swimming restrictions?	*	yes no
Any activity restrictions?	*	yes no
Please list restrictions
INSURANCE
Our church's medical insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is on a church related activity.
Do you have health insurance?	*	yes no
(If you do not have health insurance please fill out the additional Medical Insurance Waiver below and type "none" in the 'insurance carrier' & 'policy number' fields)
Insurance Carrier	*
Address
Policy number	*
*In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my child as deemed necessary.*
MEDICAL INSURANCE WAIVER (only for those without insurance)
My child, has no medical insurance. I / we, accept full responsibility for any medical expenses incurred as a result of an accident of injury that occurs during a Jamul Community Church sponsored youth activity
Parent/Guardian Electronic Signature
LIABILITY RELEASE
Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforseen events can occur. By signing this form, the parent/guardian agrees to assume and accept all risks and hazards inherent in church related activities. They also agree not to hold this church or its employees or volunteer staff liable for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release.
Please enter your name here to sign this release.
Parent/Guardian Electronic Signature	*
Security Code	*