Medical Authorization and Release of Claim Form

Towson Presbyterian Church Sponsored Activities

Classification:

___________ Youth

___________ Adult

Birthdate:_________________________

Last Name:_______________________________

First Name:_______________________________

Address:___________________________________________________________

__________________________________________________________________

Phone No.:________________________________

Date of last tetanus shot:_______________________

Medications you cannot take: ______________________________________________________________

Allergies/special health problems or concerns:_________________________________________________

_____________________________________________________________________________________

Any special information that would help advisors in working with your child (ex., never been away from home, fear of heights, etc.):

_____________________________________________________________________________________

Mother's Name:__________________________________________________________________

Address (if different from your own): __________________________________________________

Phone No.:

_____________________(Home)

_____________________(Work)

Father's Name:__________________________________________________________________

Address (if different from your own): __________________________________________________

Phone No.:

_____________________(Home)

_____________________(Work)

Insurance Co.______________________________________________________

Policy or Group No. __________________________________________________

Medical Authorization for Treatment: I understand that in an emergency, reasonable attempts will be made to contact a guardian or immediate family member. However, in the event that one cannot be contacted, I request and authorize medical personnel to provide all reasonably necessary medical care including, but not limited to, hospital tests, such as pathology, radiology, anesthesia, surgery and prescription drugs advisable for the health of myself/my child/the "participant." I acknowledge that no representations, warranties, or guarantees as to results or cures will be made.

Exemption from Liability: The undersigned, on his or her own behalf or on behalf of his or her child, hereby exempts and releases Towson Presbyterian Church and the officers, agents, servants, employees and lessors of Towson Presbyterian Church from any and all liability, claims, demands or actions or causes of action whatsoever arising out of any damage, loss or injury to the Participant or the Participant's property while upon the premises of Towson Presbyterian Church or while participating in any activities sponsored by Towson Presbyterian Church, whether such loss, damage or injury results from the negligence of Towson Presbyterian Church, its officers, agents, servants, employees or lessors or from some other cause.

This form will be carried by the responsible party in charge of youth activities and copies will be kept at the church to assure your safe care in the event of an emergency.

Signature of Parent/Guardian or Self________________________________________________________

Date:___________________________________