REGISTRATION & MEDICAL RELEASE
Name of Youth Participant
Full Address
Date of Birth Phone
Emergency contact person Phone
Name of Insurance Company Policy #
Physician Name Phone
Please list any medical allergies, medications being taken, medical problems, or other pertinent information:
I understand that, in the event medical treatment is required, every effort will be made to contact me.
However, if I cannot be reached, I give my permission to Antioch Christian Church or a Youth Coach to secure the services of a licensed physician to provide the care necessary, including anesthesia, for my child's well-being.
Signed __________________________________ Date _____________
(Parent or legal guardian)
WAIVER OF LIABILITY STATEMENT
I, the parent or legal guardian of the child listed below, release Antioch Christian Church, together with the adults in charge, from any and all claims resulting from injury or damage that may be sustained by my child while participating in the activity listed below.
Name of Youth Participant
Activity:
Date(s) of activity through:
Signed __________________________________ Date _____________
(Parent or legal guardian)