Medical Release and Liability Form
Child Name: _____________________ Grade: __________ Sex: M / F
Parent Name(s):_______________________ Email: _____________________
Home Phone: ______________________ Cell Phone: ____________________
Emergency Contact Other than Parent: ________________________________
Home Phone: ____________________ Cell Phone: ____________________
Dr.‛s Name: ______________________ Phone #: _____________________
Insurance Provider:_________________ Policy #: _____________________
Please list any medications or allergies: ________________________________
I give my student permission to take part in all events being sponsored by Christ’s Church of the Valley. I
am aware of the risks involved with these activities, both apparent and hidden. In the event that he or she
is injured while participating, I do hereby authorize and consent to any xray examination, anesthetic,
medical, or surgical diagnosis rendered under the general or special supervision of any licensed medical
staff member, emergency personnel, or caregiver of any general hospital holding a current license to
operate under the laws of the state where the services are rendered.
It is understood that this authorization is given in advance of any specific diagnosis or treatment being
required, but is give to provide authority and power to render care which the aforementioned physician, in
his or her best judgment, may deem advisable.
It is understood that effort shall be made to contact me, the undersigned, prior to rendering treatment to
my child, but that any of the above treatments will not be withheld if I cannot be reached.
I understand the nature of these events and do hereby release Christ’s Church of the Valley; its staff and
any representatives, from any liability for accidents or injury sustained by my child in conjunction these
Mother’s Name (Print) Father’s Name (Print)
Parent’s Signature Date