ࡱ> CEB bjbj *$ @@#########$##7#####333A7C7C7C7C7C7C7L9;C7#50L355C7#### X76665 ####A765A7666#i'#5R6-7n7076n<56Rn<6n<#6l3vB4T64D4333C7C76:33375555n<333333333@ I":  Southwest Community Church (ONLY SECONDARY INSURANCE SUPPLIED BY SOUTHWEST COMMUNITY CHURCH) MEDICAL AND LIABILITY RELEASE FORM (Please Print Legibly) NAME _____ _________BIRTHDAY MALE FEMALE (Print Last Name) (First Name) ADDRESS CITY  STATE ZIP PHONE IN EMERGENCY NOTIFY (Parent or Guardian)  AT THIS #  IF PARENT OR GUARDIAN IS UNAVAILABLE, CONTACT ____ PHONE # FAMILY DOCTOR PHONE # List any allergies or physical conditions that might cause concern: Please give details (include normal treatment of allergic reactions)  Date of last tetanus shot: Name and dosage of any medications that must be taken:  Any activity restrictions: Yes No What restrictions:  If your child should require medical attention at this event for injuries received or illnesses contracted prior to coming to this event, please give us the information necessary to give your child proper medical service during this event.  S.C.C. insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in case of illness or injury while your child is on this event. Do you have health insurance? (Check One) Yes No Please give the name and address of insurance company if Yes. Insurance Co. __ Policy Number Address Main Insureds Social Security # __________ MEDICAL RELEASE: In the event I cannot be reached in an emergency during the event dates as shown on this form, I hereby give my permission to the physician or dentist selected by Southwest Community Church to hospitalize, to secure proper treatment and/or order an injection, anesthesia, or surgery for my child as deemed necessary. The signature of the parent or guardian below is intended to serve as a medical release. LIABILITY RELEASE AND HOLD HARMLESS AGREEMENT:  I hereby remise, release, and forever discharge Southwest Community Church, its agents, servants, and all other persons, firms, and corporations whomsoever of and from any and all actions, claims and demands, whosoever which claimant now has or may hereafter have on account of or arising out of any accident, casualty and/or event which might happen while on any event sponsored by Southwest Community Church Signature of parent or Legal Guardian __________Date Phone Number _________________________________ Cell Phone _____________________________________ `    $ * 0 6 = z ùvhZNFNNNh]"OJQJh]"hI>*OJQJhYh]"5>*OJQJhYhI5>*OJQJhYhI>*OJQJhYhIOJQJh]"hIOJQJh]"hI5OJQJh]"h 5OJQJh]"hICJh]"hI5CJhYhI5CJOJQJaJhYhY5CJOJQJaJh]"hC5OJQJh>h;5CJOJQJaJ`> y z   ] ^   J K $a$$a$gd;gdj@hz |      " < ? _ h m - U \ ] ^ _ l    K L g z ~  ph>OJQJh]"hIOJQJmHnHuh>>*OJQJh]">*OJQJh]"hI>*OJQJh]"hIOJQJ(jh]"hIOJQJUmHnHu?K M  qIJ0B6,-$]$pqJKX%/56ꍅzdXh>hI5OJQJ+jh>hI5OJQJUmHnHuhhOJQJhOJQJh]"h<OJQJ(jh]"h>OJQJUmHnHuh]"hCOJQJh>OJQJh>>*OJQJh]"hI>*OJQJ(jh]"hIOJQJUmHnHuh]"hIOJQJh]"h]"OJQJ &'+-.;\xǼh>h]"5 h]"hCh>hC5 h]"hI jh]"hIUmHnHuh]"hIOJQJh>hI5OJQJh>h>5>*OJQJh>>*OJQJh]"hI>*OJQJh>5OJQJ-gdC(/ =!"#$% ^B 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ Normal ]_HmH sH tH JJ  Heading 1(^( @CJKH66  Heading 25JJ  Heading 36@CJOJQJkH66  Heading 4CJ..  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