2020 Medical Release Form

Please completely fill in the information for the person needing medical release

PARENT/GUARDIAN INFORMATION

Type N/A if not applicable 

RELEASE INFORMATION*

The undersigned does hereby give permission for the above mentioned child to attend, participate and ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in ALL OR ANY STUDENT MINISTRY ACTIVITIES, SPONSORED BY STILLWATER CHURCH OF CHRIST, 821 N DUCK, STILLWATER, OK BETWEEN 1/1/2020 THROUGH 1/1/2021

We (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 Medical Practice Act 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.

We (I), being 18 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant), do hereby release, forever discharge and agree to hold harmless & indemnify Stillwater Church of Christ and the directors, employees and agents & volunteers, thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in ALL OR ANY STUDENT MINISTRY ACTIVITIES OR TRIPS between 1/1/2020 THROUGH 1/1/2021 for any liability sustained by STILLWATER CHURCH OF CHRIST as a result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

405-372-3439

©2020 by Stillwater Church of Christ