CHILD Release Form for Event.

1. 8146 Quarterfield Road, Severn, MD 21144
410.551.8500 || info@heritagecc.net
EVENT MEDICAL AND TRANSPORTATION RELEASE [CHILD]
Event: Event Date(s): Ministry:
[Registrant Contact and Health Information]
Registrant’s First and Last Name: Date of Birth:
Street Address: City, State, Zip
Emergency Contact:
Relationship to Registrant:
Phone Number:
Email Address:
Registrant’s Health History:
 Diabetes
 Cardiac
 Chronic Asthma
 Nervous Disorder
 Epilepsy
 Other: _________________________________________
Registrant’s activity restrictions:
Registrant’s Allergies:
 Drugs: _________________________________________
 Asthma
 Hay Fever
 Insect Bites/Stings: _______________________________
 Other __________________________________________
Registrant’s Medications:
I hereby give my permission to the physician, nurse, or dentist selected by the representative of the Heritage Community Church to
secure medical and dental aid as required for illness or injury under a physician's orders, including transportation to and from the
necessary facilities.
Medical insurance coverage is provided under the following policy: (leave blank if not covered by insurance)
Company: Type of Policy: Policy #:
I AGREE TO ASSUME FINANCIAL RESPONSIBILITY IF MEDICAL TREATMENT IS REQUIRED FOR ANY REASON. Initials: _____________
[CONSENT AND RELEASE FROM LIABILITY]
I, ____________________________, approve of and authorize the transportation of my child/children during this event in a
private or rented vehicle by Heritage Community Church for transportation purposes.
MY CHILD/CHILDREN ARE VOLUNTARILY PARTICIPATING IN THIS EVENT, INCLUDING TRANSPORTATION TO AND FROM IT'S
RELATED ACTIVITIES, WITH KNOWLEDGE OF ANY DANGERS INVOLVED AND HEREBY AGREE TO ACCEPT ANY AND ALL
RISKS OF INJURY AS A RESULT OF SUCH PARTICIPATION AND TRANSPORTATION.
As lawful consideration for permitting myself to participate in this event with Heritage Community Church, including transportation to and from this
event and its related activities, I hereby release and discharge the Heritage Community Church, its leaders, employees and members of the Board of
Trustees from all actions, claims or demands I and my heirs, distributees, guardians, legal representatives or assigns now have or may hereafter have
for any injury or damages resulting from negligence or other acts, howsoever caused, by such related activities, church, leaders, employees and
members of the Board of Trustees, before or during my participation in this church sponsored event on and/or away from the church premises,
including transportation to and from the event and other transportation provided for related activities.
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A
RELEASE OF LIABILITY AND AN ASSUMPTION OF RISKS AND SIGN IT OF MY OWN FREE WILL.
Parent/Guardian Signature: Date:
THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.
 Physical Handicap
 Emotional Handicap
 Mental Handicap
 Seizure Disorder