Child First Name

Child Last Name

Gender

Female
Male

Street Address

City

State

Zip Code

Birthdate (MM/DD/YYYY)

Grade Level JUST COMPLETED

Age 5
Kindergarten
Pre-1st
1st
2nd
3rd
4th
5th

Are there any medical conditions/allergies we should be aware of?

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone #

Parent/Guardian Email

User Agreement

I agree to the following medical release:

In the event of an emergency, I hereby authorize an adult leader of the activity, as an agent for me to consent to any x-ray examination; medical, dental, anesthetic, or surgical diagnosis; treatment; and hospital care advised and supervised by a licensed physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are to be rendered, either at the physician’s office or in a hospital. I understand the activity director will endeavor to reach us should the nature of the injury or illness warrant it. However, we will not hold any of the activity personnel responsible if efforts to contact me (us) are unsuccessful. I further promise to hold harmless Cornerstone Church of the Nazarene and/or its employees, agents and volunteers from any and all expense incurred pursuant to this authorization in obtaining medical treatment and/or transfer, including but not limited to: ambulance expense, cost of paramedics, hospital expense and/or physician charges.

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