This is Temporary but WE are not.

Liability Release 2017

Uncategorized - October 2, 2015 - 0 Comments

ONE21 LIABILITY RELEASE FORM 2017

Student Name__________________________________Male      Female

Street Address_____________________________City______________

State________Zip___________Home Phone______________________

Parents Names: Mother:______________________Father: ________________________

Parents Home Phone (if different from student)___________________

Mom’s Cell Phone___________ Dad’s Cell Phone_________________

In Case of Emergency and parents cannot be reached please contact:

Name_____________________Phone___________Relationship______

Insurance Company:____________________________________________________

Policy Number:_________________________________________________________

Family Doctor:__________________________________________________________

Doctor City:__________________________Doctor Phone:_______________________

Current Medications:______________________________________________________

Date of Last Tetanus Shot? ______/________ (if not completed, tetanus shot will be given in case of emergency)

Medical History:

Allergies:

IN CASE OF EMERGENCY, I hereby give permission to the physician selected by the One21 leadership to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child named on this card. I understand however, that every effort will be made to contact me in case of such an emergency and if possible, before any such medical treatment is administered.  I hereby release One21 from any responsibility other than normal supervision and care. In case of accident, I will not hold Back2Back Ministries, One21,  or its Staff Members, Management, or Officers liable unless guilty of gross disregard for the safety and welfare of the student. I understand that if at any time my child(ren) shares any information that illustrates the potential for harm to themselves or others, all One21 staff  and volunteers are mandated by law to report.  

I give permission for any appropriate photographs/videos of my child to be used for future B2B/One21 promotional purposes.

____________________________ _________

Signature of Parent/Legal Guardian            Date

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