Medical Release Form

PARTICIPATION, MEDICAL AUTHORIZATION RELEASE, WAIVER AND INDEMNITY AGREEMENT

(All participants (or parent if under the age of 18), must read, sign, and date this waiver)

Participant Name:  ___________________________________

While we make every effort to provide a safe and pleasant environment for every participant who attends an activity, we do require that this participation agreement is read, filled out, signed, and dated by all participants (or their parent/guardian if under the age of 18) who wish to participate in activities at or through Brookside Baptist Church (Brookside).

With full knowledge, I accept full responsibility for any injury or accident that may occur to me, my spouse, or my child while participating in Brookside activities.  I give permission for my child to participate in activities that occur at or through Brookside sponsorship.  This includes the activities themselves and the transportation to and from the activities.

Although Brookside has taken reasonable steps to provide safe transportation and supervision so you, your spouse, and / or your child can safely participate in activities, we do remind you that these activities are not without risk.  Certain risks cannot be eliminated.  The same elements that contribute to the character of these activities can be the cause of loss or damage to your property, accidental injury or illness or, in extreme cases, permanent trauma or death.  We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about inherent risks.

For promotional or marketing purposes, Brookside reserves the right to use any video, audio, and / or photography of guests or participants in our activities.

I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Brookside, its pastors, board, agents or employees, for any and all claims for injuries, causes of action, or liability related to my child’s participation in any activity, including any attorney’s fees and costs to enforce this agreement.  This release does not apply to intentional and / or willful acts of misconduct by Brookside or any of its pastors, officers, board, agents or employees.

By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my child’s participation in these activities, I and / or my child may be found by a court of law to have waived any right to maintain a lawsuit against Brookside on the basis of any claim which has been released herein.  I have had sufficient opportunity to read this entire document.  I have read and understood it, and agree to be bound to its terms.


Signature: ____________________________________                 Date: _______________

         (you must sign your own waiver if you are 18 or over)

MEDICAL INFORMATION AND AUTHORIZATION (For participants under age 18)

Health or Behavioral Conditions (for example: epilepsy, bed-wetting, sleepwalking, seizures, etc.):  ________________________________________________________________

Drug Allergies or Other Allergic Reactions: _______________________________________

Medication Taken Regularly (must be in original container): _____________________________

Activity Restrictions: __________________________________________________________

I give permission for my child to attend the ______________________ activity at or through Brookside.  I understand that my personal insurance will provide primary coverage for medical aid.  I also understand that if my son/daughter must be sent home because of medical, disciplinary or other problems, I will assume the additional transportation cost.  IN CASE OF MEDICAL EMERGENCY, I hereby give permission to the physician selected by the Brookside activity director or his agent, to hospitalize, secure proper treatment for, and order injection, x-ray, anesthesia, or surgery for my child (or the minor) as named previously.

Insurance Company: _________________________  Policy Number: _________________

 Please check here if your child is NOT covered by insurance.

Parent’s Signature: _______________________________      Date: __________________

Contact Number: ___________________________          Cell: _________________________