Kids/Students Health & Activity Waiver

In order to have the most up to date information, we need our families to fill out our Health and Activity form. This is a form that each family needs to fill out in order to serve and love our families in a much better way!

Primary Emergency Contact Information

Your name *

Email address *

Address

Phone number

Secondary Emergency Contact

Name *

Relationship *

Phone Number *

Child's Health Information

Names and Ages of Children *

Please fill out your Children's names and ages. Example: Tyler - 14, Erin - 8

Please list any medications that we would need to know for each child: *

Example: Tyler - Tylenol, Erin - Ibuprofen.

Date of Last Tetanus Shot for Each Child: *

Example: Tyler - ???, Erin - ???

Please list any pre-existing conditions that we need to know about for each child: *

Example: Tyler - ???, Erin - ???.

Please list all known allergies for each child: *

Example: Tyler - ???, Erin - ???.

Please list any known restrictions or other special physical or dietary needs: *

Example: Tyler - ???, Erin - ???.

Name of Insurance Company: *

Name listed on Policy: *

Policy Number: *

Group Number: *

Doctor's Name: *

Insurance Phone Number: *

Doctor's Phone Number: *

Doctor's Address: *

Dentist's Name: *

Dentist's Phone Number: *

Insurance and Doctor Information

Parent/Guardian of a Minor Consent/Hold Harmless *

Being the parent or legal guardian of the children listed above, I have been informed above the activities sponsored by Hillcrest Bible Church and hereby give my consent for my minor children to participate. I understand that all reasonable safety precautions will be taken by the leaders of these activities, and that the possibility of an unforeseen hazard does exist. I further agree not to hold Hillcrest Bible Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the minors listed on this form.

I also do consent to any x-ray, anesthetic, medical, surgical, or dental diagnosis or treatment that may be deemed necessary for my minor children. Further I understand that all efforts will be made to contact me prior to treatment. In the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor children. I further understand that the doctors, dentists, and other providers attending to my child will take all reasonable safety precaution during their care.

Further, as parent or legal guardian I am responsible for the health care decisions for my minor children and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child. Any policy of the church or organization sponsoring this event will be used as the secondary coverage.

I AGREE TO ALL OF THE ABOVE
Fill in your name and date below as an electronic signature

A copy of your responses will be sent to your email address.