Student Name

First Name

Last Name

Other Students in your care

First Name

Last Name

First Name

Last Name

First Name

Last Name

Parent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Waiver Information

The above-named parent of the Minor has entrusted the Minor into the care of organization, while the Minor participates in an activity sponsored by Clairemont Emmanuel Baptist church and for the welfare of the Minor. I understand that Clairemont Emmanuel Baptist Church does not carry medical and hospitalization insurance coverage available to the aforementioned child. Therefore, I shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. I , the undersigned, do hereby release, remiss and forever discharge the paid/volunteer staff and Clairemont Emmanuel Baptist Church from any and all claims, demands, actions or cause of action, past, present or future, arising out of any injury to my said child.

MEDICAL INFORMATION

Insurance Co.

POLICY NUMBER

Claim Office Number

(###)

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SPECIAL MEDICAL CONDITIONS OF MINOR SUCH AS DIABETES, ALLERGIES AND MEDICATIONS CURRENTLY USING OR LEARNING DIFFICULTIES:

CIVIL CODE OF CALIFORNIA, SECTION 25.8

Either parent if both parents have legal custody, or the parent or person having legal custody or the legal guardian, of a minor may authorize in writing any adult person into whose care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Ace, or a dentist licensed under the provisions of the Dental Practice Act.

By clicking SUBMIT you are agreeing that the above information is accurate and you are the legal guardian of the student/s named.

Digital Youth Trip Waiver and Medical