TFC Hawaii Medical Permission Liability Release Form

FILIPINO UNITED CHURCH OF CHRIST Christian Education Ministry Waipahu, Hawaii 96797 AUTHORIZATION FOR ANNUAL MEDICAL, PERMISSION, AND LIABILITY RELEASE FORM I (We), _________________________________________the parent(s)/legal guardian(s) of _______________________________________________give my (our) child permission for him/her to participate in any activity sponsored by Filipino UCC for the fiscal year of 2010-2011 and to be transported to and from these activities under the following conditions: TRANSPORTATION DURING EVENTS: My child may (please initial ONE): ________ ride with a driver 18 years or older ________ only ride with an adult 21 years of age or older I (We) will instruct my (our) child about my (our) choice above and he/she will be responsible to comply with it. INSURANCE: I (We) understand that in the event of an accident the driver/owner’s insurance carrier is the primary source, and the Filipino UCC provides coverage, but only as a secondary source. EMERGENCY: In the event of an emergency, I (We) hereby give permission to transport my (our) child to a hospital for emergency medical, dental, anesthetic of surgical treatment. I (We) agree that my (our) insurance company will be used for such medical care expenses and I (We) am aware that the medical provider for any medical treatment expenses not covered by my insurance may bill me (us). I (We) understand that if I (We) do not have medical insurance coverage that I (We) am responsible for the payment of any medical bills. RETURNING HOME: Should it be necessary for my (our) child to return home due to medical reasons, disciplinary reasons or otherwise, I (We) shall assume all transportation costs. CAMERAS: I (We) understand that photographs and/or video may be taken with film and/or digital cameras and consent to such photographs/video of my (our) child as well as subsequent publication in media including, but not limited to, the following: internet, newsletter, newspaper, and/or periodical. SPORTS: I (We) expressly acknowledge that there are inherent risks in playing sports. M F Child’s Name Date of Birth Sex Parent’s/Guardian’s Name Parent’s/Guardian’s Name () () () () Home Phone Work Phone Home Phone Work Phone Address Address City, ST ZIP Code City, ST ZIP Code Alternative Emergency Contacts Primary Emergency Contact Secondary Emergency Contact () () () () Home Phone Work Phone Home Phone Work Phone Address Address City, ST ZIP Code City, ST ZIP Code Medical Information Hospital/Clinic Preference Physician’s Name Phone Number Insurance Company Policy Number Allergies/Special Health Considerations I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. I understand I or emergency contacts will be kept informed when medical issues arise. Parent’s/Guardian’s Signature Date LIABILITY RELEASE: I (We), as legal guardian and/or parent of the child named below, do hereby give permission for my child to participate in events with the Filipino UCC, both on the church premises and at other locations, including travel to and from such. I (We) recognize that there is risk associated with such activities and in transporting and supervising groups of children and youth on outings. As a result of this recognition, I (We), individually and in my (our) capacity as parent(s)/legal guardian(s) release, indemnify, and hold harmless Filipino UCC, its clergy, youth pastors, employees, agents, representatives, affiliates, corporately and personally and volunteers from any all demands, claims, and liability arising out of my (our) child’s participation in the program. I (We) hereby waive my (our) claim to a lawsuit against the Filipino UCC or any such persons for any liability arising out of my (our) child’s participation in these activities. __________________________________ _________________________________ ______ Parent/Legal Guardian Name Signature Date