Please PRINT legibly and fill out this form in full.
MEDICAL RELEASE
Name________________________________________________ Sex____________
Age__________
Address
City_________________________________ State_____________ Zip_________________
Home Phone_________________________
Parent's Name__________________________________________ Cell
Phone________________________________
Insurance Carrier______________________________________
Ins#____________________________________
Doctor's Name__________________________________________
Phone___________________________________
Office Location______________________ Medical Information (i.e. medication,
allergies)________________________________________
In the event of an emergency where medical treatment is required I give
permission to WFF personnel to obtain the services of a licensed physician.
Please attempt to notify the person named below (in addition to parents)
concerning any emergency.
1st Person to Notify________________________Phone# _________________ Cell
Phone#_________________
2nd Choice to Notify________________________Phone# _________________ Cell
Phone#________________
LIABILITY RELEASE
As the Parent/Guardian of the teenager listed above, I hereby give my consent
for he/she to participate in the Wheat Field Fellowship youth group (Underground
Spring). I understand that no amount of instruction, precaution, and
supervision will eliminate all risk of mishap or injury. Should an accident
occur, I release Wheat Field Fellowship and any authorized agents thereof from
any liability. I further state that by signing this form I consent to the
conditions of this agreement, and so hereby for myself, my heirs, my Executors
and Administrators, waive, release, and forever discharge any and all claims
with the rights for damages which I may have or which may hereafter accrue to me
against Wheat Field Fellowship and their respective Officers, Agents,
Representatives, Successor, and/or assigns any damages and liabilities which may
be sustained and suffered by me in connection with, participation in, or
traveling to and from the event listed below.
Fill in the event name here_____________________________________
Event & Place:________________________________________________________ Date
& Time________________________
TRANSPORTATION RELEASE My child(ren) _______________________ have permission
to be transported to and from the event listed above by a licensed adult driver.
Signature of: Youth________________________________
Date____________________________
Parent/Guardian____________________________________
Date____________________________
PHOTOGRAPHY RELEASE My child(ren) _______________________ have permission
photographed the event listed above and have the images used on the web. (We do
not use last names of kids on the website.)
Signature of: Youth________________________________
Date____________________________
Parent/Guardian____________________________________
Date____________________________