Parental Consent, Waiver, & Medical Release Form

Student Extreme Ministries- Hazel Dell Christian church

Name: _____________________________ Age: ______ Birth date: ____________

Address:__________________________________ Phone: (___)_______________
City: _______________________________ State: _______ Zip code: ___________
School: ______________________________ Grade in or just completed: _______
Parent (s) names: _____________________________________________________
Parent(s) work numbers: _______________________________________________

We (I) authorize an adult, in whose care the minor has been entrusted, to
consent to any X-ray examination, anesthetic, medical, surgical or dental
diagnosis or treatment, and hospital care, to be rendered to the minor under the
general or special supervision and on the advice of any physician or dentist
licensed under the provisions of the Medical Practice Act on the medical staff of a
licensed hospital, whether such diagnosis or treatment is rendered at the office of
said physician or at said hospital. The undersigned shall be liable and agree(s) to
pay all costs and expenses incurred in connection with such medical and dental
services given to the child on this release form.
Should it be necessary for my (our) child to return home due to medical
reasons or otherwise (ie- discipline problems, family concerns, or emergencies),
the undersigned shall assume all transportation costs. Furthermore, I understand
that in the event my child becomes unruly or disobedient, authority personnel at
Hazel Dell Christian Church reserve the right to discipline and I could be asked to
come and get my child from an event. I also agree to hold the above-named
organization harmless of and from any and all liability of whatever nature, which
may arise out of or result from participation in events, activities, or sports
sponsored by the Hazel Dell Christian Church Student Ministries.
The undersigned does also hereby give permission for my (our) child to
ride in any vehicle designated by the adult (21 or older) in whose care the minor
has been entrusted while attending and participating in activities sponsored by
Hazel Dell Christian Church Student Ministries.
I hereby give permission for my (our)child, __________________________
to attend and participate in activities sponsored by Hazel Dell Christian Church
Student Ministries.

Participant signature Printed name Date

Parent signature (if child is under 18) Printed name Date

Legal guardian (if child is under 18) Printed name Date

We take several pictures on trips and events that we use for publications & our
website. Please check this box if we can use a picture with your teen in it. ___

Please fill in medical information on the reverse side of this sheet. Thank you.
 Medical Information
Health Insurance Company:
_______________________________________________
Address/City/Zip code of company:
_______________________________________________
_______________________________________________
Phone number of company (____)_________________
Policy number/Group ID: _______________________

Emergency contact number(s):

_____________________________________________
Relationship to participant:
_______________________________________________

Please list any allergies, special medical problems, or prescription medication

your child has or takes (along with the reason) below. Thank you.

Allergies:
______________________________________________________________________
______________________________________________________________________
Special Medical Problems:
______________________________________________________________________
______________________________________________________________________
Prescription Medications/reason:
______________________________________________________________________
______________________________________________________________________

**Please give all medications to designated adult leader. Thank you!

*Note*- Your child will not be allowed to participate in an event or activity unless
both sides of this form are completed in their entirety and the form is notarized.

To be completed by a Notary Public:

County of___________________________ State

of_____________________________
Country of_____________________________
On this day of ___________________ in the year 20___, before me, the
undersigned notary public, personally appeared the above named individuals for
the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal

____________________________
(Notary Public Signature)

____________________________
(Commission Expiration Date)