MEdical/Photo Release

NOTE: If the participant is over the age of 19 they will need to complete the release form for adults. If the participant is 18 or under, a parent or guardian should complete the form below.

Medical Release (Adults)

Student's Information

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Do we have permission to give your child access to Ibuprofen or Tylenol?

Yes

Tylenol only

Ibuprofen only

In the case of an allergic reaction, do we have permission to give your child Benadryl?

Yes

Medical conditions, food or medication allergies or any other allergies:

List medications taken regularly:

Insurance Info

Insurance Company

Policy Number

Group Number

Parent/Guardian Information

First Name

Last Name

Phone Number

Alternate Emergency Contact

In the event that the parent/guardian can not be contacted during an emergency, the best available alternate contact is:

First & Last Name

Phone Number

Relationship to Participant

PERMISSION, ACKNOWLEDGEMENT, RELEASE
We, the undersigned parents/guardians of the above named youth, grant permission for the youth to participate in the various outings, or any other event sponsored or attended by Hillcrest Evangelical Free Church. We as parents/guardians, have been advised of the nature and extent of the activities that may take place and represent to you that the participant is physically and mentally able to participate in the those activates.We as parents/guardians, understand that this activity, as in any activity for young people, does present the risk of injury, or even death, to the participant, rare as they may be, and we have advised the participant of those possibilities. We represent to you that we and the participant assume the risk of any such injury or death, and hold you, your agents, employees, and representatives harmless from any liability to any other person or entity arising as a result of the conduct of the participant in this activity and agree to defend the indemnify you, your agents, employees and representatives against any claim or liability arising as a result of such contact.If we, as parents/guardians, are not personally present at these activities, Hillcrest Evangelical Free Church is authorized on our behalf to arrange for such medical and hospital treatment as you may deem advisable for the health and wellbeing of the participant. We authorize you to transport our child in the church van, rental vehicles, or automobiles provided. We further more give permission for adult volunteers to confront and take appropriate measures necessary if our child refuses to abide by the rules, safety guidelines, curfew or authorities present.I understand this agreement and by signing below agree to the above terms.

PHOTO RELEASE
I/We, the undersigned grant Hillcrest Evangelical Free Church permission to use photographs/video of the above named youth, in its publications (emails, slideshows, promotional material, the HEFC website, and social media outlets.

Signature

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