Deep River 13 - Emmanuel Community Church

Liability Release &
Medical Consent
The undersigned does hereby give permission for my abovenamed child to attend this event sponsored by Emmanuel
Community Church and to participate in all activities.
I authorize an adult in whose care the minor has been entrusted, to
consent to an X-ray examination, anesthetic medical, surgical or
dental diagnosis or treatment, and hospital care to be rendered to
the minor under the general or special
supervision and on the advice of any physician
or dentist licensed under the provisions of the
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Medical Practice Acts on the medical staff of a
licensed hospital, whether such diagnosis or
treatment is rendered at the office of said
physician or at said hospital.
The undersigned shall be liable and agrees to pay all costs and
expenses incurred in connection with such
medical and dental services rendered to the
aforementioned child pursuant to the
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authorization. Should it be necessary for my
child to return home due to medical reasons or
otherwise, the undersigned shall assume all
transportation costs.
The undersigned does also hereby give
permission for my child to ride in any vehicle
designated by the adult in whose care the
minor has been entrusted while participating in
the activity sponsored by Emmanuel
Community Church.
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The undersigned acknowledges that he or she is advised and
aware of the nature of the activities planned for this event. I also
understand that there is some risk inherent in such
activities. I consent to the minor's full
participation in such activities and agree to
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hold Emmanuel Community Church and its
agents and representatives harmless for any
injury related directly or indirectly out of such
activities or the transportation to or from such
activities.
I hereby grant, voluntarily and with full
understanding, a license to the use and storage
of still or moving images of my dependents, by
means of digital or film photography, video
photography, audio recording or other
documentation, with respect to this activity.
Signature of Guardian
Insurance Company
Policy Number
We have a jam packed
summer and we want you to
be a part of it. Be sure to
check out the following
dates:
Wednesday Connections
-July 17: BBQ
-July 24: Yo Yo’s
-July 31: Tin Caps
July 21: Slip N’ Slide
August 25:
-End of Summer Bash
Please Initial
Date
Emmanuel Community Church
12222 West Jefferson Blvd.
Fort Wayne, IN 46814
1234 Main Street Anytown, State 54321
260-672-3377
T: (123) 456-7890 F: (123) 456-7891
www.emmanuelcommunity.org
W: www.apple.con/iwork
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high school
RIVER WATERPARK
Wednesday, July 10
8:30 am - 9:00 pm
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$20
P RIVER WATERPARK
It’s summer, it’s hot, and that can only mean one
thing--it’s time to cool off. There’s no better way to
cool off than spending the day soaking wet at a
waterpark. Grab a friend or two and bring them
along on this one day event to Deep River Waterpark
in Merrillville, Indiana. Below is important
information that you need to know.
JULY 10
We’ll leave ECC @ 8:30 am
REGISTRATION FORM
We’ll return to ECC @ 9:00 pm
Are you ready? Follow this quick and
easy registration process:
ª
This one costs you:
You Turn in this side
One piece swimsuits must be worn
You Keep this side
You’ll need money for two fast food meals
• Check with mom/dad or guardian
• Fill out this side of the form
• Have the folks read & sign the back
• Put the form in the black box by the
office
• Registration is due back July 7
Name:
Address:
City/State/Zip:
E-mail:
Phone:
Grade:
Medical Concerns/Medications:
In Case of an Emergency
In the event of an extreme emergency on the day of this event, you
may contact Todd at 797-3265 or Brian at 444-1303. Please use
these numbers only in the event of an extreme emergency.
Student may be given:
❑ Tylenol
❑ Pepto Bismol
❑ Benadryl
❑ Immodium