Discipline, Liability and Medical Release Form

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(Make two copies after completion. Keep one for your records and send one to us.)

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Name Gender Male Female

Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Birthday January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990

Hm Ph E-mail

Church attending with

City/State Youthworker

Parents/Legal Guardians (with whom you live)Will they be at IMPACT? Yes No

Prescription Plan Policy#

Known Allergies

Last Tetanus January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

Current Medications

Family Doctor Phone#

Address

We acknowledge that we are allowing our child to participate entirely upon our own initiative, risk, and responsibility. We further expressly authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and/or hospital care under the general or special supervision, and on the advice of, a licensed physician, surgeon, anesthesiologist, dentist or other qualified medical personnel acting under their supervision, for our child, should the same become necessary because of illness or injury. We acknowledge that our child understands that all participants are expected to abide by the IMPACT rules and be directly responsible to the IMPACT Director. The Director assumes responsibility for discipline at IMPACT and, if necessary, may, because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for returning the minor home. Now therefore, in consideration of the permission extended to our child to participate in IMPACT 2008, we do hereby for ourselves, our child, our heirs, executors and administrators, remise, release and forever discharge the IMPACT Director and staff, the Churches of God, General Conference, its officers, members, The University of Findlay, as well as all other participants and sponsors of IMPACT 2008, acting officially or otherwise, from all claims, demands, actions or causes of action of any kind including the death of our child or any injury to our child or loss or damage to property which may occur from any cause during IMPACT 2008. It is our intention by this document to consent to our child’s participation in IMPACT 2008 and to waive and forego all right of action of ourselves and our child against the parties herein before named.

Signature of Parent/Legal Guardian: ___________________________________________ Date

Person to notify in event you cannot be reached:

Name Relationship

Phone#

THIS FORM MUST BE INCLUDED WITH REGISTRATIONS FOR ALL
MINORS (UNDER 18 YEARS OF AGE) ATTENDING IMPACT.

*Name of adult leader responsible for you at IMPACT

Cell Phone# if available