Grace Community Church
Grace Youth – Student Activity Registration Form
Youth Leader: Pastor John Everett
I, the undersigned parent or guardian of ____________________, a minor, do hereby authorize adult workers of Grace Community Church to consent to any examination,x-rays, anesthetics, medical or surgical diagnosis or treatment and hospital care which is rendered under supervis ion of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of the said physician or at said hospital.
Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering services. I also hereby release Grace Community Church; it’s staff and volunteers from any liability for injury that my child may sustain during this church activity.
Insurance Company or Group: ______________________________________
Policy Number: _________________________________
(Please print the following information)
Name of Participant: ___________________________________
Parent or Guardian: ____________________________________
Address: ____________________________________________
City: _____________________ State:________ Zip: ___________
Daytime Phone: _____________ Evening Phone: _________________
Signature of parent or guardian: _______________________________________
Church Activity: _______________________________________
