Liability Release Form and Health Information Event: _______________________________________________________________________________ Name ____________________________________ Date of Birth ____________ Age ________ Sex ____ Address __________________________________ City ___________________ State _______ Zip ____ Emergency Contact: ____________________________________________________________________ Phone ____________________________________ Work or Cell # ______________________________ Name of Insurance Company ___________________________________ Policy # __________________ Name of Insured _____________________________________________ Group # __________________ Family Doctor _____________________________ Phone # ____________________________________ Are You [Or Your Student] on Prescription Medications? Yes No Are You [Or Your Student] Taking Over the Counter Medications? Yes No If You Answered “Yes” to the Above Questions Please Provide: Medication ________________________________ Dosage _________________ Frequency __________ Medication ________________________________ Dosage _________________ Frequency __________ If your you/ your student should require medical attention for injuries received or illnesses contracted prior to activity, please include the necessary information to give him/her proper medical care during the trip, i.e. any pre-existing or present medical conditions (diabetes, food or drug allergies, asthma) or activity restrictions: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Medical Release Statement I understand that in the event medical intervention is needed, every attempt will be made to contact the persons listed on this form. In the event I cannot be reached in an emergency during this trip, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and or order injection, anesthesia, or surgery for my child as deemed necessary by the physician. I understand all reasonable safety precautions will be taken at all times by LAKESHORE CHRISTIAN FELLOWSHIP and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold LAKESHORE CHRISTIAN FELLOWSHIP or ICFG, its leaders, staff, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject on this form. I agree to abide by all guidelines given by the leadership of Lakeshore Christian Fellowship, Eleven and SPLASH. I understand that failure to abide by these guidelines will result in a warning, loss of privileges, and/or dismissal from the trip at my own or my parent’s expense. Parent / Guardian Signature _______________________________________ Date____________ Student Signature (if applicable) ___________________________________ Date____________