Medical and Liability Release Form

September 2010 to August 2011

Student’s Name_________________________________Birth Date_________________Age_______

Address____________________________________City____________________Zip____________

Student’s E-Mail _______________________  Parent’s E-Mail ______________________________

Phone______________________Social Security Number____________________________________

Parent’s Name______________________________________________________________________

In Emergency, notify:________________________________________Phone____________________

Physician__________________________________________________Phone____________________

City______________________________________________________Zip______________________

Heath History - Allergies and Other Conditions

__Insect Allergies                                                                                             __Heart                        __Other Allergies

__Frequent Upset Stomach                                                                  __Epilepsy                   __Asthma

__Drug Allergies                                                                                               __Diabetes                   __Hay Fever

If you checked any of the above, please give details (i.e., include normal treatment of allergic reaction):___________________________________________________________________

___________________________________________________________________________

Date of last tetanus shot:_________________

Name and dosage of any medications that must be taken:______________________________

___________________________________________________________________________

Swimming Restrictions:___Yes___No   If “yes,” explain:_____________________________

__________________________________________________________________________

Our church’s 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 son or daughter is on a church-related activity.

Do you have health insurance?___Yes___No   If “yes,” name:__________________________

Policy #______________________Address________________________________________

“In the event that I cannot be reached in an emergency, 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 son or daughter as deemed necessary.”

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 or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities.  They also agree not to hold this church, its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned.  The parent or guardian understands that they are signing for the minor listed on this form and the signature is for both medical and liability release.

Parent or Guardian’s Signature______________________________Date_________________

(Parent’s signature must be notarized.)

Notary_________________________    Date_______________      Seal:

State of South Carolina             County of: _______________________

Commissioner’s Expiration:   ______/______/_____

Please complete BOTH sides and return to Cornerstone Church, Attn: Nathan Aylestock, 5637 Bush River Road, Columbia SC 29212