This medical release is valid for the Year of 2018, starting on January 1, 2018 to December 31, 2018. This is required for all students that desire to participate in any Student Ministry Activity, Event, or Trip during 2018. 

Student
Name *
Name
Birthday *
Birthday
Address *
Address
Parent/Guardian
Parent/Guardian 1 *
Parent/Guardian 1
Parent/Guardian 2
Parent/Guardian 2
Emergency Contact
In case a parent/guardian cannot be reached...
Emergency Contact *
Emergency Contact
Medical Information
Please list any Medical Conditions that your student has; if none type "none."
Please list any allergies your student has; if none, type "none."
Please list any medications your student takes and dosages; If none, please type "none."
Medical Release Statement
Agreement and Acknowledgement *
DISCLAIMER Marietta Community Church and its leaders, directors, officers, employees, contractors, agents, volunteers, members and representatives (collectively referred to as “Marietta Community Church and/or MCC”), are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, activities or travel with Marietta Community Church and all related activities associated with Marietta Community Church, including injury, loss or damage. ASSUMPTION OF RISKS IN CONSIDERATION OF Marietta Community Church allowing me or my child to participate in events, activities, or travel with MCC and all related activities associated with the MCC, including participation in the Student Ministry and all activities related to the Student Ministry (collectively referred to as the “Activities”), I acknowledge that I am aware of the possible Risks, Dangers and Hazards associated with participation in the Activities including the possible risk of severe or fatal injury to myself or others. RELEASE OF LIABILITY and AGREEMENT IN CONSIDERATION OF Marietta Community Church allowing me or my child to participate in the Activities, I agree on behalf of myself and/or my child: 1. TO ASSUME and ACCEPT ALL RISKS arising out of, associated with or related to my or my child’s participation in the Activities. 2. TO WAIVE and RELEASE Marietta Community Church from any and all liability for any loss, damage, injury or expense that I or my child may suffer, or that my next of kin may suffer as a result of my or my child’s participation in the activities due to any cause whatsoever. 3. TO INDEMNIFY and HOLD HARMLESS Marietta Community Church from any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from my or my child’s participation in the activities. 4. TO INDEMNIFY and HOLD HARMLESS Marietta Community Church from any and all claims, demands, actions and costs for any loss, injury, damage or expense whatsoever that might arise out of my or my child’s participation in the Activities. YOUTH PARTICIPATION CONSENT Acknowledgment of Participant: I, the undersigned Participant, understand that I am responsible to act in a safe and responsible fashion, to follow the instructions or directions of the persons in charge of the Student Ministry, and to obey requests to comply with safety regulations as directed by the persons in charge of the Student Ministry, including designated leaders and drivers of private or public transportation. I will be solely responsible for myself, will wear a seat-belt when available and will not disturb or distract the driver when using private or public transportation to travel to and from Student Ministry activities. At all Student Ministry sports events or other activities, I acknowledge that it is my responsibility to obtain and wear appropriate safety equipment. I will not endanger the safety of others or myself at any activities, outings or sports events of the Student Ministry or when using private or public transportation for travel to and from such activities. I also understand that I may be photographed or appear in video for such purposes as MCC deems necessary. ACKNOWLEDGEMENT OF PARENT/GUARDIAN OF PARTICIPANT: We, the undersigned Parents or Guardians of the Participant, hereby authorize and consent to the Participant’s involvement in the Student Ministry, including any use of private or public transportation deemed necessary by the persons in charge of the Student Ministry for Participant travel to and from Student Ministry activities, or to the NEAREST SUITABLE MEDICAL or HOSPITAL FACILITY in the event that emergency or other medical treatment not available at the site of a Student Ministry activity is deemed advisable. We hereby consent to and authorize such emergency or other medical treatment of the Participant as may be deemed advisable in the event of accident, injury, or illness during the activities of the Student Ministry. We also understand that the participant may be photographed or appear in video for such purposes as the MCC deems necessary. ACKNOWLEDGEMENT and SIGNATURE I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT that is binding upon myself and my heirs, executors, administrators, successors and assigns. I HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT and I ACKNOWLEDGE THAT by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that my child or I may have.
Date *
Date