Hamilton Assembly of God
    Medical Release / Permission Form
    Valid June 1, 2023 - June 30, 2023


    Child's name                                                                                    Date of Birth

    Street                                                                                City                                                            Zip

    Parent/Legal Guardian

    Cell Phone                                                                    Alternate Phone

    Please name a relative or close friend we may contact if we are unable to reach the above in case of emergency

    Name                                                                             Phone


    I understand that in the event professional medical intervention is needed for a participant in a church related activity, a reasonable attempt will be made to immediately contact the designated parent or guardian listed on this form.  In the event I, or the doctor listed below, cannot be reached in an emergency during the activity dates shown on this form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order an injection, anesthesia or surgery for my child as deemed necessary.  Hamilton Assembly of God Church will not be financially responsible for services rendered.

    I hereby release Hamilton Assembly of God Church, its staff members, its governing organizations, its officers, trustees, employees, agents, and all other persons associated with Hamilton Assembly of God Church from any and all liability, damages, claims, demands, actions and causes of actions of any kind or description arising out of or in any way related to any activities that I may participate in or at Hamilton Assembly of God Church.  The undersigned does hereby further agree to indemnify and hold harmless any party herein released from claims brought by any party herein or by any third party arising out of or in any way related to any actions or activities while at a Hamilton Assembly of God Church activity.  I understand this release is binding upon my heirs, executors and assigns.

    Permission is given to Hamilton Assembly of God to use photographs (individual or group) and/or multimedia images and recordings of my child.

    Signature of Parent/Guardian                                                                    Date

    Please provide the following information:

    Medical insurance:    Yes__________        No __________

    Policy or contract #: ______________________________

    Doctor: ___________________________________________   Phone____________________

    Hospital preference: ______________________________________________________________________
    Date of last tetanus shot: _________________

    Known allergies or medical conditions: _______________________________________________________________

    Any restrictions? (swimming, skiing, etc.): ____________________________________________________________