Student Medical Release 2018-2019 Question Title * 1. Student #1 Information First Name Last Name Gender Date of Birth mm/dd/yyyy Email Cell xxx-xxx-xxxx Anticipated High School Graduation Year Question Title * 2. Student #2 Information First Name Last Name Gender Date of Birth mm/dd/yyyy Email Cell xxx-xxx-xxxx Anticipated High School Graduation Year Question Title * 3. Student #3 Information First Name Last Name Gender Date of Birth mm/dd/yyyy Email Cell xxx-xxx-xxxx Anticipated High School Graduation Year Question Title * 4. Student #4 Information First Name Last Name Gender Date of Birth mm/dd/yyyy Email Cell xxx-xxx-xxxx Anticipated High School Graduation Year Question Title * 5. Parent/Legal Guardian Information Name Email Cell xxx-xxx-xxxx Family Address (including city/state/zip) Question Title * 6. Additional Parent/Legal Guardian Information Name Email Cell xxx-xxx-xxxx Question Title * 7. Other Emergency Contact Information Name Relationship to Student Phone xxx-xxx-xxxx Question Title * 8. Medical Insurance Information Company Name Name of Insured Policy/Group # RxID/Group # Insurance Company Phone # Question Title * 9. Medical History: please list and explain any health problems or chronic medical conditions. If necessary, describe in detail the nature and severity of any physical and/or psychological condition of which the staff should be aware and what, if any, action of protection is required. If none, answer NA. Student #1 Student #2 Student #3 Student #4 Question Title * 10. Please list and explain any major illnesses the student experienced during the past year.If none, answer NA Student #1 Student #2 Student #3 Student #4 Question Title * 11. Please list medications, prescription and non-prescription, taken regularly.If none, answer NA. Student #1 Student #2 Student #3 Student #4 Question Title * 12. Please list any known allergies (food, drug, environmental, etc). If none, answer NA. Student #1 Student #2 Student #3 Student #4 Question Title * 13. Please list any activity restrictions. Student #1 Student #2 Student #3 Student #4 Question Title * 14. Date of last tetanus shot Student #1 Student #2 Student #3 Student #4 Question Title * 15. Physician Information Name Phone Question Title * 16. Dentist Information Name Phone Question Title * 17. Photo Release: I give permission for any videos or photographs taken of the above named student(s) to be used on the WHPC website and/or WHPC social media and/or any WHPC publication. Yes No Question Title * 18. Behavior Contract: I understand and agree that I have informed the student(s) named above of the behavior expectations listed below and he/she/they has/have agreed to abide by them. I understand and agree that if said student(s) fails to comply with these expectations, he/she/they will be sent home and I will incur all expenses related to transporting him/her/them home.Student Behavior Expectations:>No students can drive without proper authorization>No possession or use of alcohol, drugs, tobacco or pornography>No fighting, weapons, fireworks, lighters, explosives, etc.>No offensive or immodest clothing>No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters>Participation with the group is expected>Respect property>Respect one another, staff, and adult leaders>Respect and comply with event schedules I agree Question Title * 19. Parental Consent: The above named student(s) has/have my permission to attend all youth activities sponsored by Westlake Hills Presbyterian Church from August 19, 2018 to August 19, 2019.This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Westlake Hills Presbyterian Church (hereinafter “WHPC”) and its staff of any liability against personal losses of named student(s). I have legal custody of the student(s) named above and have given our consent for him/her/them to attend events being organized by WHPC. I understand that my electronic signature below carries with it the following:> I am aware that activities may include participation in sporting/recreational events. (Note: if you desire to limit your student’s participation in any event, please submit your wishes in writing to the WHPC Youth Ministries Director(s) prior to that event.)> I give permission for the above named student(s) to be transported to and/or from church-sponsored events and church-approved meetings by: A) church provided transportation (cars, vans, buses, planes) and/or B) adult driven transportation (WHPC Youth Staff, adult volunteers). I also understand that my student(s) may have one-on-one meetings with WHPC Staff or Volunteers.> In the event that the above named student(s) is/are injured, or should require medical or dental attention while participating in a church-sponsored event, I hereby authorize the church representatives or sponsors of the event to secure necessary medical treatment for the above named student(s). I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provided. I affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student(s) named above. I further understand that it is solely my/our responsibility to notify the WHPC Youth Ministry of any changes regarding the above named student’s health, medical insurance, or guardianship information. I do hereby specifically release, waive, discharge, and covenant not to sue WHPC, its staff, volunteers, agents, and governing bodies, for any action or causes of action, including, but not limited to, personal injury, property damage, or wrongful death, which may exist or which may hereafter arise during and following the participation of the above named student(s) in a church-sponsored event occurring between the dates listed on this form. I further understand and agree that in the event that the above named student is involved in activities that violate or compromise the rules, policies, or purposes of WHPC, I will accept full responsibility for release of the above named student(s) to my/our custody and care. I further understand that I/we will cover all financial costs if the above named student is sent home for disciplinary reasons.> I have read and understand this form, and hereby state that all information is true and correct. Unless terminated in writing, this release shall be effective August 19, 2018 through August 19, 2019 only. I agree Question Title * 20. Electronic Signature (E-signature) Agreement: By entering your name, initials and the date of signature, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. By entering your name, initials and date of signature, you consent to be legally bound by the terms and conditions contained in this form. Name Initials Date of E-signature Done
