2011 - 20112 High School Medical Release Form

General Information
Name: Address: City/State/Zip: Parent(s) Name: Cell Phone: DOB: School/Work: Home Phone: Parents Work Phone: Student/Participant SSN: Grade:

Emergency Contact Information

Name: Address: Home Phone: Relationship: City/State/Zip: Other Phone:

Medical Information
Family Physician: Clinic: Insurance Company: Co-pay amount: Members Name: Health History: Allergies or Other Conditions ____Insect Allergies ____Epilepsy ____Food Allergies ____Drug Allergies ____Diabetes ____Other Allergies ____Hay Fever ____Frequent Colds ____Frequent Stomach Upset ____Heart Phone: Group No.: Company Sponsor: Insurance Co. Phone:

Please specify/explain below if you checked any of the above allergies or conditions. ___________________________________________________________________________________________ Date of Last Tetanus Shot: Physical Handicaps or Special Conditions: Swimming Restrictions: ____Yes ____ No Activity Restrictions: ____ Yes ____ No List Special Accommodations Required: Please Explain: Please Explain: Medications Being Taken: None:

Medical and Surgical Waiver: I am the parent and/or legal guardian of ___________________________________ and hereby acknowledge that he/she is under my care, custody, and control. In the event there arises an emergency necessitating medical/surgical attention, I expressly grant my permission and consent to the East Cooper Baptist Church staff, its representatives, sponsors, or any attending physician, to make such decisions and to perform such medical treatments and/or surgery upon my child listed above which may in their sole discretion be necessary and proper under the circumstance. I, the undersigned parent and legal guardian of above mentioned child, do release, acquit, discharge, and covenant to indemnify and hold harmless East Cooper Baptist Church or its representatives, the sponsors, or any attending physician, from any and all actions, causes of actions, related risks and dangers, including negligence, damages, liabilities arising out of the treatment of any sickness or accident, and any financial responsibility for all medical treatment provided. Property Damage, Transportation for Disciplinary Reasons and Personal Property Searches: I also assume financial responsibility for any damage my child may cause, and for providing transportation home should it become necessary for disciplinary reasons. I also give my permission to the East Cooper Baptist Church staff, its representatives, and the adult sponsors and chaperones to search my childs personal belongings, including but not limited to all luggage, purses, and backpacks, if deemed necessary for security reasons. Insurance Changes: I also understand that it is my responsibility to notify the church of any changes in my insurance information. Photo Disclaimer: By signing this form, you give permission to allow your students photograph to be taken while participating in any ECBC program or event. These photos may be used in slideshows and promotional information purposes including display on the ECBC website. Please notify us in writing if you object to your student being photographed.

Signature of Parent/Guardian:

Date:

ECBC High School Ministry Mission Trip/Retreat Guidelines 2011-2012

1. I understand that I need to respect the authority of the Student Ministry Leaders/Chaperones. I understand they have the authority to put in place additional guidelines specific to certain mission trips and retreats. I will honor these guidelines as well as the ones below. 2. I understand that there will be no arguing or complaining on this trip! (see Phil. 2:14) 3. I understand and will honor the established electronics guidelines. Cell Phones and iPods will be allowed, but only at appropriate times. 4. Dress in good taste (shorts of appropriate length, t-shirts with appropriate sayings, modest swimwear, no spaghetti straps). 5. I understand that, for safety reasons, I must stay in groups of 3 or more people at all times. Also, for safety, I will wear a seatbelt at all times while in a vehicle. 6. I understand the need for separate sleeping arrangements, and will honor this by never entering the room of a person of the opposite sex. I understand that I need to abstain from public or private displays of affection. 7. I understand that I am to treat the property of others with respect and will not damage the place we are staying or another persons personal belongings. I understand I am obligated to pay for the replacement/repair of items I have participated in damaging. 8. I understand that I cannot be outside of my room after lights out. 9. I understand that Im not allowed to POSSESS or USE tobacco, alcohol, or any other type of drugs. I understand that Im not allowed to POSSESS or USE any weapon or fireworks. 10. I understand that Im not allowed to prank, haze, harass, threaten, or intimidate another student or adult. Consequences for Breaking Guidelines 1-5 These actions will be confronted once, and activity time will be taken away if appropriate. If deemed appropriate by Jonathan, further action will be taken and student will be sent home at their familys expense. 6-10 These actions will result in the student being sent home immediately at their familys expense. I will follow the above guidelines and respect ECBCs leadership. I understand the consequences if I choose not to follow these guidelines. ______________________________________ _________________________________ Students Signature Print Name

______________________________________ _________________________________ Parents Signature Print Name 3