CCC Student Release Form
CCC Student Release Form
Student's Name:*
Date of Birth:*
Gender*
Address:*
Parent/Guardian's Name(s)*
Parent/Guardian Cell Phone:*
If the person(s) named above is not available in case of an emergency, notify (name, relationship, number):*
Name of Physician:*
Physician's Phone:*
Health Insurance Carrier:*
Policy Number:*
Taking any medications?*
Allergies (food, medicines, insects, plants, etc.)*
Medical conditions to be aware of:*
Do we have permission to give your student over-the-counter pain relievers if needed as evidence by student's statement or behavior?*
I do hereby release, forever discharge and agree to hold harmless Cicero Christian Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in Church Activities. The undersigned further hereby agrees to hold harmless and reimburse said church, its directors, employees, chaperones, and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto. The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless said church, its directors, employees, chaperones, and agents from failure to act on the part of those chosen to administer medical care on behalf of the participant.
Parent/Guardian Signature for above information:*
Date:*