The River Church Community

The River Church Community
 701 N. 1st Street San Jose, CA 95112 408.252.5500
, www.the-river.org

Student Ministries Consent and Release From Liability 2008-2009
Valid September 2008 - August 2009 (note: if information changes please submit new form)

Student Name _____________________________________  Birth date _________________________
Mailing Address___________________________________  City __________________  Zip _________
Grade in Fall 2007 (current grade) _______________________  Gender __________
Parent/Guardian Names _____________________________________________________________
Home Phone _________________________________  Student Cell Phone _____________________
Mother's Contact Phone ________________________  Father's Contact Phone ___________________

Throughout the year we will need to contact parents AND students through e-mail.
Please PRINT information carefully and clearly distinguish between letters and numbers.

Parent email _________________________________________________________________________


Student email  ________________________________________________________________________

MEDICAL INFORMATION AND RELEASE

Doctor's Name _____________________________  Phone (      ) _______________________________
Medical Insurance Company ____________________________  Policy # _________________________
List all allergies _______________________________________________________________________
______________________________________________________________________________
List all medications ____________________________________________________________________
____________________________________________________________________________________

I, _____________________________ give my permission for __________________________________
    (Parent or Guardian)                                (Student Name)
to participate with other youth and adults from The River Church Community on any and all events or trips that will occur from September 2008 through August 2009. In the unlikely event of an emergency, I give my permission for my student to be treated by an accredited physician in an approved emergency clinic or hospital. I designate the adult leaders for the group with the authority to act on my behalf and order appropriate treatment. I further release from any liability The River Church Community and its officers and approved emergency clinic leadership, in the event of any accident en route during and returning from these events. I expect to be contacted as soon as possible.
    * If we cannot provide proof of medical insurance, I will sign a waiver releasing liability (see back/next page)


                 Signature of Parent or Guardian                                                               Date signed

Please include a photocopy of your student's medical insurance card!












Liability Waiver September 2008- August 2009

NOTE: Please complete and sign only if you do not have medical insurance for your student.

I _____________________________ do not have medical insurance for my
 
child ____________________________ .

I understand that my child attending any youth events that The River Church Community will not be responsible for any emergency medical expenses incurred.

I also understand that The River Church Community will not be held liable for my child's actions that might involve a law suit.

Parent Signature ___________________________________________

Date __________________________