Parent/Guardian 1 Information
Parent/Guardian 2 Information
This information will be requested by the physician and medical facility in the event of an emergency. Please help us by making sure you give complete and correct information. This Medical/Release form is valid for one year to date of Parent//Guardian signature. If any of the information you have provided should change before this date, please complete a new form and return it to the church office.
The undersigned, as parent or guardian of the person listed, hereby authorizes any staff member and/or adult sponsor who may be supervising or directing any activity sponsored by Chisholm Summit Community Church to authorize emergency medical treatment for the person listed above while this person is participating in any trip, excursion, or sponsored activity by Chisholm Summit Community Church.
Furthermore, I release the Chisholm Summit Community Church, its staff, employees, and sponsors from any liability for personal injury, damage, or loss that the above named person may sustain while participating in and/or traveling to any activity sponsored by Chisholm Summit Community Church, even if such personal injury or other loss by the ordinary negligence of Chisholm Summit Community Church, its employees, staff members, or designated sponsors.
I agree to allow the staff and sponsors selected by Chisholm Summit Community Church to discipline my child during any activities if, in the sole judgement of such staff sponsor or other designated sponsor, such discipline is necessary. I have explained to my child the attitude and actions expected during such activities. If any staff sponsor or the designated sponsor deems it necessary for my child to return from any trip due to illness, injury, or misconduct, I agree to be responsible for all costs associated with such a return trip.
