Solid Rock Community Church

Solid Rock Community Church Medical & Liability Release Form

Please fill out this form completely.page 1 of 1





PERSONAL INFORMATION


First Name Last Name
Address
Address Line 2
City State Zip Code
Phone Number



MEDICAL INSURANCE




PLEASE NOTE: Solid Rock Community Church's insurance is a secondary policy. Your insurance needs to make a determination regarding the claim, then the church policy will respond.

PARENT/GUARDIAN INFORMATION


First Name Last Name
Address
Address Line 2
City State Zip Code
Phone Number


IN CASE OF EMERGENCY (who to call in case a parent/guardian is unable to be reached)


First Name Last Name
Phone Number

PERSONAL PHYSICIAN


First Name Last Name
Phone Number


PERMISSION TO PARTICIPATE AND RELEASE OF LIABILITY

I give my permission for my son/daughter

First Name Last Name


and consent and agree to indemnify and hold harmless Solid Rock Community Church, its agents, employees, or volunteer assistants from all claims that I or the church might have arising out of my child's participation in this program which is over and above that which is covered by insurance. I have explained the meaning of "hold harmless" to my child, and the signature below indicates his/her agreement to do the same.





EMERGENCY MEDICAL CARE AND TREATMENT

If it should become necessary for my child to receive medical treatment for any reason, I understand that the medical insurance policy for Solid Rock Community Church acts in a primary position only when the participant is not already covered by insurance. Consequently, I agree to submit all claims first to my insurance company then to the insurance company for Solid Rock Community Church. I also accept full responsibility for the cost of medical treatment for any injury suffered while taking part in the program, which is over and above that which is covered by insurance. In addition, I authorize and consent to all medical, surgical, diagnostic, and hospital procedures as may be performed or prescribed by a physician to safeguard my child's health, and it is not advisable to take the time to contact me in advance. I waive my right to informed consent for such treatment. Moreover, I understand that temporary emergency measures may be necessary to safeguard my child's health, and I do hereby authorize and request personnel from Solid Rock Community Church to administer to supervise such treatment and to do any procedure that it deems necessary until such time as my child can be safely transported to a doctor or hospital.





* required