Rock Bible Church Student Ministries Liability Release Form

Personal Information

First Name:

Last Name

Age:

D.O.B:

Address:

Phone:

Email:

This address will receive a confirmation email

Emergency Contact Name

Emergency Phone:

Doctor:

Phone:

Dentist:

Phone:

Insurance Company:

Policy Number:

Address

Insurance ID #:

Medical History

Allergies

Please Check List of Allergies Below and add what the allergy is and the normal treatment to reactions, type of reactions etc. Drugs: Hay Fever Hives/Rash Insect Bites/Stings: Foods: Special Dietary Needs/Restrictions: Vegetarian:

Allergy Information:

Have you been in the hospital during the past 2 years?

Yes No

Have you been under the care of a medical doctor during the past 2 years?

Yes No

Have you had surgery? If yes, please list date & type:

What medicines do you take now? List name and dosage:

Date of last Tetanus:

Any special intructions or information about selected medical information above:

Restrictions

Swimming restrictions:

Yes No

Other restrictions:

Other pertinent medical information:

If participant should require medical attention for this trip for injuries received or illnesses contracted prior to coming on this trip, please send us the information necessary to ensure proper medical service if necessary/List any other medical information or special needs we should be aware of:

LIABILITY WAIVER, RELEASE AND MEDICAL AUTHORIZATION

WHILE ROCK BIBLE CHURCH MAKES EVERY EFFORT TO PROVIDE A SAFE AND PLEASANT ENVIRONMENT FOR YOUR CHILD, WE DO REQUIRE THAT THIS PARTICIPATION AGREEMENT BE READ, FILLED OUT, AND SIGNED AND DATED BY THE PARENT OR LEGAL GUARDIAN OR EACH CHILD WHO WISHES TO PARTICIPATE IN THE ACTIVITIES/TRIPS PLANNED AND/OR HELD BY ROCK BIBLE CHURCH.

The undersigned participant(and participant's parent(s)/guardian(s), if applicable) hereby authorizes ROCK BIBLE CHURCH, Pleasanton, California, acting through any adult volunteer or leader or other authorized agent, to consent to medical care(including, for example, any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and dental diagnosis or treatment) and/or hospital care to be rendered to the participant by or under the supervision of a physician and surgeon or dentist licensed under applicable law. This authorization is given pursuant to California Civil Code section 25.8 and shall remain in effect for the duration of the trip, unless revoked in writing by participant or participant's parent or guardian, as the case may be. ROCK BIBLE CHURCH and its volunteers, employees and agents are authorized to release medical information provided to them by participant(or participant's parent(s)/guardian(s) if applicable) to medical providers and emergency personnel in connection with any medical treatment provided to, or medical evaluation of, participant.

If participant is unable to complete the planned stay on the event identified above for any reason, participant(and participant's parent(s)/guardian(s), if applicable) will reimburse ROCK BIBLE CHURCH for the reasonable cost of transporting participant from the event to ROCK BIBLE CHURCH. I further agree to pay all incurred charges for dental, medical, or hospital care or treatment provided to, or medical evaluation of, participant.

Participant(and participant's parent(s)/guardian(s), if applicable) authorizes ROCK BIBLE CHURCH and its partners and agents to use, copy, reproduce, display, distribute, publish and exhibit, in an appropriate manner, without restriction any pictures, video, audio reproduction or narrative, description of the participant that may be created with respect to the event. Participant(and participant's parent(s)/guardian(s), if applicable) waives any right participant9and participant's parent(s)/guardian(s), if applicable) might have to inspect and/or approve such items or the use to which they may be put.

Participant(and participant's parent(s)/guardian(s), if applicable) hereby releases and forever discharges and agrees to hold harmless ROCK BIBLE CHURCH and its pastors, trustees, employees, volunteers and agents from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, that may arise from participant's activities in connection with the event. Participant (and participant's parent(s)/guardian(s), if applicable) understands and acknowledges that this RELEASE discharges ROCK BIBLE CHURCH and such persons from any liability or claim against ROCK BIBLE CHURCH or such persons with respect to bodily injury, personal injury, illness, death, or property damage that may result from participation of participant in the event. ROCK BIBLE CHURCH does not assume any obligation to provide financial or other assistance to participant (or participant's parent(s)/guardian(s), if applicable), including but not limited to medical, health or disability insurance, in the event of injury, illness, death or property damage.

Participant (and participant's parent(s)/guardian(s), if applicable) understands that this RELEASE applies to, covers and includes unknown, unforseen, unanticipated and unsuspected damages, losses or liability and the consequences thereof, that result from the activities of this event as well as those now known to exist.

I(we) certify that the information provided above is correct and I(WE) HAVE READ, UNDERSTAND AND AGREE TO THIS LIABILITY WAIVER, RELEASE AND MEDICAL AUTHORIZATION.

PRINT participants first and last name:

Participant signature:

Date:

PRINT Parent or Guardian first and last name:

Parent or Guardian signature:

Date:

Regular

ROCK BIBLE CHURCH, 4100 FIRST ST, PLEASANTON, CA 94566 (925)-931-0644

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Rock Bible Church Student Ministries Liability Release Form

Description

Please Fix the Following