Joyonline.org

Trips, Retreat, and Activity Agreement
Medical Release Agreement
2013-2014
This form is valid for ALL Community Church of Joy Trips, Retreats, and Activities during the school year
beginning August 1, 2013 and ending July 31, 2014. This agreement must be completed in full and
signed by the parent or guardian of the student before a student can participate in any of the above
referenced activities.
Student’s Name
MEDICAL INFORMATION
*Allergies to medicines/other allergies: *Medication Being Taken (drug interaction effects): *Medical History (past surgeries, current medical condition, etc.) Permission to give student over-the-counter medicine, i.e. Tylenol, Dramamine, etc. yes  no Date of Last Tetanus Booster Please use the back of this form to provide any pertinent details about medications or medical history; this would be important in the event of an emergency room visit. Emergency Numbers: Parent (Cell) I understand that participation in the above referenced activities involves risks and may result in various types of injury including, but not limited to the following: sickness, bodily injury, death, emotional injury, and/or property damage or financial damage. In consideration for the opportunity to participate in the above referenced activities I acknowledge and accept the risks of injury associated with participation in and transportation to and from these activities. I accept personal financial responsibility for any injury or other loss sustained during the activity or during transportation to or from activity, as well as any medical treatment rendered. I give my permission for the above named student to participate in Community Church of Joy and the Bridge Student Ministries trips, retreats, and activities for the school year of 2013-2014. Furthermore, I hereby release and promise to indemnify, defend, and hold harmless the Bridge Student Ministries, Community Church of Joy, its affiliates, pastors, staff, volunteers, and sponsors for any liability for any illness or injury that my child may sustain during the activities, including transportation to and from said activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to an x-ray examination; medical, dental or surgical diagnosis; treatment and hospital care advised and supervised by a doctor, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are to be rendered, either at the doctor’s office or in the hospital. I expect to be contacted as soon as possible if an emergency occurs. Additionally, I also give my permission for my child’s image to be used in any Community Church of Joy publications, promotional materials, JOY website and/or slide shows. I also understand that if my child so chooses to partake in any inappropriate behavior I am responsible for all costs and/or decisions to remove him/her from the event. In like manner, I give permission for my child to be transported in a motor vehicle driven by Community Church of Joy staff or adult volunteer identified to an event at the specified location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. I have read, understand, and discussed with my child that: (1) They will be traveling in a motor vehicle driven by an adult and they are to wear their safety-belt while traveling; (2) They are expected to respect each other, the vehicles they ride in, and the people they travel with during the trip; (3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other (4) They are to remain in their seats and not be disruptive to the driver of the vehicle. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge the Bridge Student Ministries, Community Church of Joy, its affiliates, pastors, staff, volunteers, and sponsors from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.

Source: http://www.joyonline.org/students/Medical_Release_Form_2013-2014.pdf