1260 Wesley Lane, Auburn, CA. 95603 (530) 889-9089
Medical, Liability. and Photo Release
PLEASE PRINT
Child’s Name ______
Address ______City______Zip ______
Parents’Name ______Home Phone ______
In Emergency Notify ______Phone ______
Family Doctor ______City ______Phone ______
Health History______
Allergies ______
Date of last tetanus shot ______
Name and dosage of any medications that must be taken ______
Any activity restrictions: Yes ______No ______Explain______
In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the leadership of his/her team to hospitalize, to secure proper treatment and/or order an injection, anesthesia, or surgery for my child as deemed necessary.
I hereby release Sierra Grace Fellowship, its agents, employees, and volunteer assistants from any liability whatsoever arising out of any injury, damage or loss that may be sustained by said person during event.
I hereby request team leaders to carry out any discipline deemed necessary for my child. I also agree, if necessary, that I will pay the expense of my child being sent home because of disciplinary action.
Insurance Company ______Policy # Number ______
PHOTO RELEASE
I hereby grant Sierra Grace Fellowship permission to use my child’s likeness in a photograph in any and all of its publications, including web or internet entries, without payment or any other consideration. I understand and agree that these materials will become the property Sierra Grace Fellowship and will not be returned. I hereby irrevocably authorize Sierra Grace Fellowship to edit, alter, copy, exhibit, publish or distribute photos for purposes of publicizing Sierra Grace Fellowship programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein the likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to use of photos.
Parent’s signature ______Date ______