NFOCUS ALL-PURPOSE RELEASE FORM

 

      In consideration for being accepted by  THE FIRST BAPTIST CHURCH OF CLARE for participation in NFOCUS YOUTH ACTIVITIES , we (I), being 21 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 19 years of age or older) release authorization and permission for said church to furnish any necessary transportation, food, and lodging for this participant.

      (If the participant has not attained the age of 19 years):  We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in NFOCUS YOUTH ACTIVITIES, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment.

     Further, should it be necessary for the participant to return home due to disciplinary action or otherwise, we (I) hereby assume all transportation costs.

 

Name of participant   _______________________________ Parent(s) Names   _______________________________ Parent(s) telephone   Hospital Insurance    o yes  o no   Insurance Co.____________________   Policy number____________________   Physician Name__________________   Physician’s phone_________________   Emergency Contact________________   Emergency phone_________________

If under 19, both parents must sign unless  parents are separated or divorced in which  case the custodial parent must sign.)   _______________________________  Father                                              Date   _______________________________ Mother                                               Date   _______________________________ Legal guardian;                                Date   _______________________________ Participant, if age 19                        Date   Allergies________________________   Medical Problems_________________