Medical Form For:  

Student Information:

Date of Birth: 

Parent or Guardian Information:

Completing This Form:

Work Phone:  
Cell Phone:  
Email Address:  

Other Parent or Guardian:

Work Phone:  
Cell Phone:  

Health Insurance Information:

Insurance Company:  
Group Number:  
Policy Number:  

Medical Card Link:  

Health Information:

Allergies / Recent Illnesses or Injuries / Current Medications / Other Health Information

Estimated Date of Last Tetanus Booster:  

I give permission for  to participate in this St. Paul Church sponsored event, which in this case involves . I understand that all youth and children's events may involve certain risks of physical activity and possible and that there is a risk of injury associated with the activities. Nonetheless I wish to have my child participate in this activities and ASSUME THE RISK of participating. I agree to WAIVE, RELEASE from LIABILITY, INDEMNIFY, HOLD HARMLESS AND COVENANT NOT TO SUE St. Paul Church, and their officers, employees, volunteers and agents (hereinafter the RELEASEES) from any and all claims and/or causes of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child's participation in this St. Paul Church sponsored event, including claims arising out of the negligence of the above-mentioned RELEASEES.

I (we) the parent(s) or legal guardian(s) of the participant, do hereby grant permission for our child to participate fully in the activities of , and all of its activities and hereby give permission to take said participants to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery and I (we) fully and completely assume all responsibility for all medical bills. I (we) the parent(s) or legal guardian (s) of the participant does hereby grant permission for our child to participate fully in the Camp chosen by St. Paul Church. I/We assume all risks and hazards incidental to the conduct of the activities and transportation to and from . We do further hereby waive, release, absolve, indemnify and hold harmless, Saint Paul Church and any of their respective affiliates, successors, agents, employees, members, representatives, adult sponsors, and other volunteers involved in the activities, and transportation and associated with the event from any and all claims, including claims of personal injuries to my/our child/youth or property damage, and specifically including those claims resulting from the negligence of Saint Paul Church and any of their respective affiliates, successors, agents, employees, members, representatives, adult sponsors, and other volunteers. If I cannot be reached, I authorize the authorities of the program to make whatever arrangements the circumstances allow.

I (we) the parent(s) or legal guardian(s) of the participant do hereby understand that any participant with high fever, other signs of infections or with uncontrollable behavior problems will be returned to the home.

Liability Release Agreement: I give permission for to participate in this St. Paul Church sponsored event.  I understand that all youth and children’s events may involve certain risks of physical activity and possible injury and that St. Paul Church, its program staff, and volunteers will provide each participant with reasonable care, but that St. Paul Church cannot guarantee that my child will remain free of injury.  I nonetheless wish to have my child participate in this activity and ASSUME THE RISK of participating.  I agree to RELEASE from LIABILITY, INDEMNIFY and HOLD HARMLESS St. Paul Church, and their officers, employees and agents (hereinafter the RELEASEES) from any and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child’s participation in this St. Paul Church sponsored event.  This release, however, is not intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence.

I give permission for to be transported by the St. Paul Bus, or in the personal vehicles of St. Paul volunteers / Staff Member

In the event that becomes ill or is injured during participation in this St. Paul Church sponsored event my signature indicates my permission for him/her to be treated by a physician, hospital and/or medical clinic.

Conduct Agreement: I agree that my child or youth will abide by the rules as set forth by the program staff, chaperones, and counselors of St. Paul Church, as well as any additional rules made by program staff, chaperones, and chaperones associated with St. Paul Church.  In the event that my child, disregards the rules set forth by the program staff, chaperones, or counselors of St. Paul Church, he or she will be subject to removal from this event at the expense of the parent(s) or guardian(s).