www.citychurchtxk.com
Date
City Church of Texarkana
City Church Youth
PO Box 3234 • Texarkana, TX 75503
Phone: 903-792-6331 • Fax: 903-792-6331
www.citychurchtxk.com
STUDENT REGISTRATION MEDICAL I LIABILITY RELEASE FORM
INSTRUCTIONS: Complete the Registration form in its entirety. Signatures are required on both front and back of this form. Parent or legal guardian signature is
required on both front and back of this form. All requested information is applicable. Type or print legibly in dark ink.
Student's Name: ____ _
Last (indicate name used)
First
Middle
Address:
Street
Apt #
City
State
Zip
Birth Date:
Age Now: Gender: (M/F) __ School Grade: _
Home Phone: ( ) Email:. Social Security #: _
Parent I Legal Guardian: _
Relationship to You: _
Parent I Legal Guardian Phone Number: Daytime ( ) _
Evening ( ) _
Other ( ) _
Parent / Legal Guardian Email: _
Have you ever been convicted of a felony? Yes No If yes, please explain: _
MEDICAL INFORMATION
In the event of an accident or special health needs, it will be necessary for us to have the requested information.
Please make certain that you provide thorough and accurate medical information.
Recent Serious Injury? / Yes / No
Recent Surgery? / Yes / No
Medications you take occasionally (headaches, etc.) / Chronic Medical Condition? / Yes / No
Other Health Concerns? / Yes / No
Do you plan to bring these or any other medications to event with you? / If YES to any of the above, please describe:
Yes / No / Special Diet?
All medications must be brought in the original bottle (prescription or over the / Date of last Tetanus Shot? / Immunizations Current? / --
Counter), properly labeled as prescribed by law. A current Authorization to / Allergies: / Food? / Drugs?
Administer Medication MUST accompany the meds. / Insect Stings/Bites? / Other?
Person to notify in Event of Emergency: ______
Phone Number of Contact Person: Daytime ( ) _
Family Physician:
Medical Insurance Co.
Insured ID or Member#:
Evening ( ) _
Relationship to You: _
Other ( ) _
Phone: ( ) _
Plan or Group #: _
Ins. Co. Phone #: ( ) _
It is recommended that you attach a front & back photocopy of your family medical insurance card.
x _
Required Parent or Legal Guardian Signature
Phone Number
I, being the legal guardian of give my permission to City Church of Texarkana staff, sponsors, or designees to provide medical treatment that may be deemed necessary to insure the well-being of the named student. I, the
undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge all from any and all claims, demands, actions or
cause of action arising out of damage or injury while participating in City Church of Texarkana sponsored events and activities.
IMPORTANT... SEE REVERSE SIDE FOR MANDATORY STUDENT AND PARENTAL RELEASE & SIGNATURE
AGREEMENT TO ATTEND, PARTICIPATE,
ASSUMPTION OF RISK AND RELEASE OF LIABILITY
The City Church of Texarkana hereby referred to as the "Church" requires a signature for all attendees or participants of special events and activities.
Furthermore, this form releases the Church to photograph and/or use photographs of students for use in its publications, advertising, promotional purposes,
internet, and/or visual presentations which inform people of the services and activities of the Church. The signature provided confirms Agreement to Attend,
Participate, Adsorption of Risk, and Release Form in order to participate in special events and activities.
Events and activities may include rigorous physical activities as well as exposure to the elements, animals, and insects. The Church takes all reasonable
precautions to ensure a safe and enjoyable experience. The decision to attend Church events/activities and the decision to participate in any Church activity at any
level IS AT ALL TIMES COMPLETELY UP TO THE INDIVIDUAL'S CHOICE, and if there is attendance at the Church event/activity and participation at any level
of any Church event/activity, there is a risk, which must be assumed by each attendee and by each participant. Although it is the Church's goal to maintain the
physical, emotional and social safety of each attendee and participant of the Church event/activity, the physical, emotional and social risks must be assumed by
each attendee and participant.
"I understand that attendance of Church events and activities and participation in Church events and activities may be physically and emotionally demanding.
recognize the inherent risk of physical and/or emotional injury of attending Church events and activities and participating in any and/or all activities. I understand
that each participant must assume the risk of any injury, physical and/or emotional, and any financial responsibility that could result from attending Church events/
activities and participating in Church events/activities. I agree to assume such risks and such responsibility. I. on my behalf, and on behalf of my heirs and
assigns, hereby release, indemnify and hold harmless The City Church of Texarkana from any and all claims, physical and emotional, including
bodily injury, that I may have that may be sustained in connection with my attending Church events and activities and with my participation in any andl
or all Church event activities.
If you feel that there are any activities in which you or your child should not be involved in, please describe for us on an attached sheet the activities. I understand
that the staff and/or leadership of The City Church of Texarkana reserves the right to dismiss, without refund, any student whose influence is detrimental to
the operation of events or activities. I understand that the use of alcohol, tobacco products and illegal drugs is strictly prohibited at all Church events and activities.
I have read (or had read to me) this complete document and I understand the information contained herein. I have freely and voluntarily signed this document.
Date
Date
x. _
Required Student's Signature
x _
Required Parent or Legal Guardian Signature
(if student is 18 years of age or younger)