Electronic Medical Release Form | Lincoln Presbyterian Church

Medical Release Form August 1, 2021-July 31 2022

Lincoln Presbyterian Church Release Form

This form is for August 1, 2021 - July 31, 2022, every minor needs to have a medical release form on file with the church.

Parent/Guardian Information

Primary Parent/Guardian Contact Name*

Primary Parent/Guardian Contact Phone*( ) -

Primary Parent/Guardian Contact Email*

Primary Address*

Secondary Parent/Guardian Contact Name*

Secondary Parent/Guardian Contact Phone*( ) -

Secondary Parent/Guardian Contact Email*

Insurance Information

If none, please type NONE. All fields are required.

Insurance Company*

Policy Number*

Physician*

Physician's Phone Number*( ) -

Dentist Name*

Dentist Information*( ) -

Emergency Contact

Emergency Contact*

Cell Phone*( ) -

Relationship*

Child's Information

Full Name*

Birthdate*

Gender*

Male

Female

Cell Phone( ) -

Grade Level*

The grade your child is currently in.

Please list any health restrictions and/or know allergies.

If your child is taken any medication, please list that above.

Read and Sign Here:

THE ABOVE STUDENT INFORMATION AND HEALTH HISTORY IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

By typing your name below you agree with the statement above.*

CONSENT AND AUTHORIZATION FOR MEDICAL TREATMENT

I hereby authorize Lincoln Presbyterian and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this Lincoln Presbyterian into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child under Sections 6901, 6902, and 6910 of the California Family Code.

The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic,

medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice

of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.

I have read and understand the Consent and Authorization for Emergency Medical Treatment.*

By typing your initials above you are signing your agreement to this statement.

RELEASE, WAIVER, AND INDEMNITY AGREEMENT

IT IS THE INTENTION OF US, BY THIS AGREEMENT TO EXEMPT AND RELIEVE LINCOLN PRESBYTERIAN AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF MY CHILD CAUSED BY ANY ACT OF NEGLIGENCE OF LINCOLN PRESBYTERIAN AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES.

For and in consideration of permitting my child to observe, or use any facility or equipment of LINCOLN PRESBYTERIAN or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at: LINCOLN PRESBYTERIAN in Stockton, California, during this year, the undersigned parent and/or guardian hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to my child as a result of my child's observing or using facilities or equipment of LINCOLN PRESBYTERIAN, or engaging in or receiving instructions in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue.

The undersigned parent or guardian of my child, for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against LINCOLN PRESBYTERIAN or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless LINCOLN PRESBYTERIAN and its officers, agents, servants, or employees from any and all claims or causes of action by my child or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian present any claim against LINCOLN PRESBYTERIAN and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by LINCOLN PRESBYTERIAN and said persons.

The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal

force and effect.

I have read and understand the Release, Waiver, and Indemnity Agreement.*

By typing your initials above you are signing your agreement to this statement.

CHURCH IMAGE CONSENT & RELEASE

I, the legal parent/guardian hereby authorize and consent to the use of images or videos of my child/children listed above, with or without their name(s), by Lincoln Presbyterian of Stockton, CA for purposes including but not limited to: promotional materials, printed publications, internet posts including social media, television, and other media sources. I do this with full knowledge and consent and waive all claims for compensation for use or for damages. I release Lincoln Presbyterian, its officers, trustees, employees, and agents from liability for any claims by me or any third party in connection with the use of the image of my child/children listed above.

If you DO NOT WANT PICTURES OR VIDEOS posted, you may type your initials here:

KEEP INFORMATION CURRENT AGREEMENT

As Parent/Legal Guardian it is my responsibility to inform Lincoln Presbyterian Church if any of the above information changes throughout the academic year.

I have read and understand that I must keep all information current.*

By typing your initials above you are signing your agreement to this statement.

SIGNATURE OF PARENT/LEGAL GUARDIAN

I agree with the Consent and Authorization for Medial Treatment, Release, Waiver, and Indemnity Agreement, Church Image Consent & Release, and Keep Information Current Agreement.

SIGNATURE*

By typing your name above you are signing your agreement to this statement.

Today's Date*

Please leave this field blank.