General Liability Release Form - Lakeshore Christian Fellowship

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____________