Medical Release

You must fill out one form for each person who is attending any event outside of the Carolinas Cornerstone campus. This form is valid for one calendar year.
Anyone under 18 must have the guardian ‘digitally sign’ the document at the bottom.

Your name *

Email address *

Phone number *

Gender *

Birthdate *

Marital status

Medical note *

Please include OTC and medicine allergies, spice and food allergies, medicine you currently take, and any known medical conditions that an EMT or hospital would need to know. Write NA if none

Date of Tetanus shot?

If only year is known please write out in four digits (i.e. 2018) If you don't know, write unknown.

Can you swim? *

Well (I can save you)

Good (I won't drown)

Need floaties

Emergency Contact Info

Emergency Contact First Name *

Last Name *

Phone number *

Relationship? *

For ex: spouse, guardian, betrothed, sibling etc

Consent for emergency treatment

Note: If you should require medical attention while on an activity with the above listed church/group for injuries received or illness contracted prior to coming, please provide trip coordinators with information necessary to give proper medical service during the trip.

In case of an emergency, I hereby give permission to the physician at the nearest hospital to hospitalize, secure proper treatment for and order injection, anesthesia, or surgery for myself as named above.

I, therefore, agree to assume as an explicit condition of my participation, any and all risks, including, but not limited to these enumerated above. I agree to hold harmless the above-named sponsor, the sponsoring church or group from any and all inabilities, claims, demands, and causes of action whatsoever which may arise due to the participation of myself.

I realize, also, that in the event of illness or injury while participating in its activities, medical treatment may be required. I hereby give permission for any such treatment to be rendered, and I agree to bear the cost of such treatment. If any changes occur, I will contact the director.

Consent for emergency treatment *

Yes

Photo release *

I grant permission to Carolinas Cornerstone Church for the use of the photograph(s) or electronic media images of my child in any presentation of any and all kind whatsoever when used by the church. I understand that I may revoke this authorization at any time by notifying Carolinas Cornerstone Church in writing.

Yes

Digital signature *

By typing your name in this box below, you are digitally signing this form. If under 18 parent must sign.

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