NorthPointe Community Church

NorthPointe Community Church
Office/mailing address: 2787 W. Bullard, #101 Fresno, CA 93711
(559) 276-2300
[email protected]
www.northpointe.org
www.npkids.org
MEDICAL RELEASE & CONSENT FORM FOR TRAVEL
All information below must be completed by the child’s Parent or Guardian:
Child’s name: ________________________________________ MALE FEMALE Age: ______ Birth date: __________________
School: _____________________________________ Current Grade: _____ Invited by: _________________________________________
Father: _______________________________________ Phone: __________________ Texting? YES NO Carrier: ________________
Father’s Email: _______________________________________________ Regular attender at NPCC? YES NO
Mother: ______________________________________ Phone: __________________ Texting? YES NO Carrier: ________________
Mother’s Email: _______________________________________________ Regular attender at NPCC? YES NO
Child’s Primary Address: ___________________________________________ City: __________________State _____ Zip: ____________
Who lives at this address? Father Mother
Both
Other: ____________________________________________________
If “yes” to any of the following questions, please explain in space provided below:
 Has your child had any surgery or serious illness within the last 3 years? YES
 Is your child required to take any medication?
YES
NO
 Does your child have any allergies or allergic reaction to any medication? YES
 Is your child presently under a doctor’s care for specific health concerns? YES
NO
NO
NO
______________________________________________________________________________________________________
______________________________________________________________________________________________________
If above Parent/Guardian cannot be reached, contact the following person in case of EMERGENCY:
________________________________________
Name
_______________________________
Preferred Emergency Phone #
____________________________________
Relationship to child
Health Insurance Company: _____________________________________________ Policy #: ________________________________
Subscriber’s Name: ___________________________________________ Ins. company phone: ________________________________
Doctor’s Name: _________________________________________________ Phone: ___________________________________________
Please read each section below, and initial the corresponding box to acknowledge your consent:
 CONSENT AND RELEASE FROM LIABILITY: The child on this form has my permission to participate in all activities of NorthPointe
Community Church and to be transported by private car when necessary. I understand all events will have adult supervision. In
consideration of the benefits to be derived from these activities, I hereby voluntarily waive any claim against NorthPointe Community
Church, the sponsors, and the owner/or driver of the car or bus furnishing transportation to any event. I further agree to direct my
son/daughter to conform to the fullest with the directions and instructions of the sponsors in charge.
 MEDICAL CARE PERMIT: In the event I cannot be reached, I hereby authorize emergency medical care or first-aid treatment as
needed for the child on this form in the event of illness or injury during any sponsored activity of NorthPointe Community Church. I
understand that NorthPointe will attempt to contact me or the additional emergency contact if medical attention is needed.
 I give NorthPointe Church permission to use photos/videos that may include my child (for promotional use only, i.e. brochures, web, etc.).
 I give NorthPointe Church permission to use my email address for church communications only (information, activities, events, etc.)
 I understand that ALL payments are non-refundable and non-transferable (cannot be used for another child or activity).
 This Medical Release & Consent Form is in effect until I give NorthPointe Community Church written notice to the contrary.
Parent/Guardian Signature: ____________________________________Today’s Date: ________________
Minor(s) (under age 18) identified for this release:
_____________________________
__________________________________
_____________________________
__________________________________
MINOR (UNDER AGE 18) PARENT/GUARDIAN
RELEASE, WAIVER AND INDEMNITY AGREEMENT
I, THE UNDERSIGNED, LEGAL PARENT OR GUARDIAN, WISH TO VOLUNTARILY PERMIT MY SON(S) AND/ OR DAUGHTER(S)
OR WARDS, NAMED BELOW, TO PARTICIPATE IN ACTIVITIES AT SUGAR PINE CHRISTIAN CAMPS, OAKHURST,
CALIFORNIA. ACTIVITIES MAY INCLUDE, BUT ARE NOT LIMITED TO:
HIGH ROPES CHALLENGE COURSE, LOW ROPES CHALLENGE COURSE, ZIP LINE, PAINTBALL, CLIMBING
STRUCTURES, POOL AND POND ACTIVITIES, ORGANIZED GAMES AND EVENTS WHICH MAY INCLUDE ARCHERY,
BB GUN FIRING, FRISBEE, BICYCLING, TRAIN RIDES, AND ANY AND ALL PERSONAL CHOICE ACTIVTIES MY SON(S)
AND OR DAUGHTER(S) CHOOSE TO EXPERIENCE.
ADVENTURE RECREATION MINIMUM AGE AND SIZE REQUIREMENTS
HIGH ROPES CHALLENGE COURSE: 13 YEARS OLD AND 4’10” TALL
PAINTBALL: 12 YEARS OLD OR ENTERING 7TH GRADE
LOW ROPES CHALLENGE COURSE: 10 YEARS OLD
CLIMBING STRUCTURES: 6 YEARS OLD
I FULLY RECOGNIZE THE DANGERS AND HAZARDS INHERENT IN CAMPING ACTIVITY, AND ANY RELATED
TRANSPORTATION; INCLUDING PERSONAL INJURY, PROPERTY DAMAGE, OR WROGFUL DEATH, AS WELL AS THE
UNKNOWN DANGERS AND HAZARDS WHICH MAY ARISE IN MY SON(S) AND/OR DAUGHTER(S) PARTICIPATION IN THE
CAMPING ACTIVITY, DO HERBY VOLUNTARILY:
AGREE FOR MYSELF, MY HEIRS AND PERSONAL REPRESENTATIVE(S), TO DEFEND, HOLD HARMLESS, INDEMNIFY,
RELEASE AND FOREVER DISCHARGE, TO THE BROADEST EXTENT ALLOWED BY CALIFORNIA LAW, SUGAR PINE
CHRISTIAN CAMPS, THEIR TRUSTEES, OFFICERS, EMPLOYEES, AGENTS, INSURERS, SUCCESSORS AND ASSIGNS;
FROM AND AGAINST ANY AND ALL CLAIMS, DEMANDS, ACTIONS, OR CAUSES OF ACTION ON ACCOUNT OF ANY
DAMAGE TO REAL OR PERSONAL PROPERTY, OR ANY PERSONAL INJURY OR DEATH THAT MAY RESULT FROM
MY SON(S) AND/OR DAUGHTER(S) PARTICIPATION IN ALL ACTIVITIES.
The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or
has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction
offered, assumes all risks associated with such dangers and risks, and is fully aware and understands the legal consequences of
signing this Release. The undersigned parent or guardian intends his or her signature to be a complete and unconditional release of
all liability to the greatest extent allowed by California law and if any portion of the Release is held invalid, it is agreed that the
balance shall, notwithstanding, continue in full legal force and effect.
PRINTED NAME (Parent or Guardian)
SIGNATURE (Parent or Guardian)
8-2014