Medical & Liability Waiver Student's Name * First Name Last Name Parent Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent Phone * (###) ### #### Student Birthdate * Health Insurance Provider * If none type "none" Policy # * If none type "none" Is your student taking any medication? If so, please list: * Medication or food allergies: * Emergency Contact (other than self) * Emergency Contact Phone * (###) ### #### Relationship to Student * By signing my name, I, the legal guardian of the participant, give consent for the participant to attend and participate in the customary events sponsored by New Life Community Church such as, but not limited to; swimming, BBQs, Game Nights, hiking, overnighters, sports, concerts, boating, camping, mission trips, and camps from July 1st, 2022 to July 1st, 2025. I understand that there will be adult supervision at each event. If there are any changes in the information I present on this document, I will notify New Life Community Church immediately. In addition, I have, and do hereby, release New Life Community Church employees, agents, sponsors, and affiliates from any liability associated with participation in such church activities. I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth. This document is valid until revoked in writing by the undersigned and delivered to the church office at 8155 W Thunderbird Rd, Peoria, AZ 85381. * I, the parent/guardian of the child named above on this form, do hereby authorize New Life Community Church and its adult leadership as agents for the undersigned to administer over the counter non-prescription medications including but not limited to Tylenol, Advil, and cold medications in dosages appropriate for the above named child’s age, and to clean and bandage or wrap wounds as necessary. I, also, consent to any emergency x-ray, examinations, anesthesia, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given in advance to provide authority and power to the aforesaid agents. The expense of such treatment is agreed to be the sole obligation of the undersigned, and New Life Community Church is hereby released from responsibility to pay for such services rendered. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury. * I agree I do not agree (my child can not participate) Today's Date * MM DD YYYY Thank you!
