Medical Release Form

indicates a required answer

MEDICAL INFORMATION, AUTHORIZATION AND RELEASE FORM

This form is intended to universally cover all activities that may be held under the direction of New Horizons Homeschool Group and/or Celebration Community Church from August 2021 through July 2022.

1. *	LAST NAME OF FAMILY:

GENERAL INFORMATION

2. *	Father's name

3. *	Father's cell phone #

4. *	Mother's name

5. *	Mother's cell phone #

6. *	Address, City, State, Zip Code

7. *	Email address

8. *	In the event neither parent can be reached, please provide two alternative contacts, including their phone #s and relationship to child.

INSURANCE INFORMATION

9. *	Does your child have insurance coverage?

10. *	Insurance company

11. *	Policy #

12. *	Primary policy holder

MEDICAL INFORMATION

Please fill out the requested medical information for every adult and child who attend NHHG. After submitting doctor information for the first family member you may indicate "same" for the others if the same doctor cares for all family members.

13. *	Name

14. *	Date of birth

15. *	Doctor (including phone #)

16. *	Allergies/sensitivities/medications

17. *	Name

18. *	Date of birth

19. *	Doctor (including phone #)

20. *	Allergies/sensitivities/medications

21.	Name

22.	Date of birth

23.	Doctor (including phone #)

24.	Allergies/sensitivities/medications

25.	Name

26.	Date of birth

27.	Doctor (including phone #)

28.	Allergies/sensitivities/medications

29.	Name

30.	Date of birth

31.	Doctor (including phone #)

32.	Allergies/sensitivities/medications

33.	Name

34.	Date of birth

35.	Doctor (including phone #)

36.	Allergies/sensitivities/medications

NOTARIZED AUTHORIZATION AND RELEASE

Celebration Community Church and/or New Horizons Homeschool Group leaders, members and teachers shall not be held liable for any injury, personal injury, damage, loss or accident which may occur because of my or my child's participation in any event, class, or activity associated with, held by or sponsored by Celebration Community Church and/or New Horizons Homeschool Group. I understand that Celebration Community Church and/or New Horizons Homeschool Group are not responsible for any injury or medical conditions which may occur during my or my child's participation in activities or events offered by Celebration Community Church and/or New Horizons Homeschool Group.

I authorize any person associated with Celebration Community Church and/or New Horizons Homeschool Group to obtain emergency medical care as deemed appropriate at the discretion of Celebration Community Church and/or New Horizons Homeschool Group in the event a parent, guardian, or emergency contact cannot be reached in a timely manner. I release Celebration Community Church and New Horizons Homeschool Group and all persons associated with them in any manner of all liability in obtaining or declining to obtain emergency medical care for me or my child.

37. *

By selecting the "I Accept" button and typing your name on the signature line, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" button and typing your name on the signature line, you consent to be legally bound by this Agreement's terms and conditions.

(1 required)

I ACCEPT

38. *	FULL SIGNATURE NAME