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Health Release:
Please list any health conditions, medical prescriptions, and any health problems that would require special limits on activities:
Participant Permission and Liability Release:
I will be participating in the College and Young Adult Florida 2004 Retreat, sponsored by the Central Church Student Ministries Department. In order for me to participate in activities sponsored by Central Church, I understand that I will be responsible for any medical expenses for myself. I understand that the church highly encourages all participants to have health and accidental coverage in place.
____________ I do have health insurance.
____________ I do not have health insurance.
I understand and acknowledge that by signing this form I am authorizing any staff member, if in their sole discretion it is necessary, to administer first aid, contact the family physician for medical treatment, summon emergency medical care, or transport to a medical facility for treatment.
I hereby waive any legal right or claim against Central Church, Inc., its staff, volunteers, and/or its Board of Directors that I, or my heirs or successors might have as a result of injury incurred by participation in any activity, or travel to and from such activity.
Participant Name: ______________________ Date of Birth:_________
(please print)
Signature: ____________________________ Date: ____________
Personal Information
Address: ______________________ Phone: h________ w________
City, State, Zip: _________________________________________
Email address: _________________________________________
Church Affiliation: ________________________________________
Home phone: _______________ Work phone: __________________
Need Transportation? ($10) _____
Emergency Contact for Medical Treatment
Name: ____________________________ Relationship: __________
Family Physician: ________________________________________
Phone: ________________________________
Please supply a copy of your insurance card, front and back, showing the name, address, phone and policy number of the company. Send or fax this to the address or number below and designate it for Randall Johnson.
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Central Church
2005 Winchester Blvd.
Collierville, TN 38017
Phone:901-255-8153
Fax: 901-255-8198
Email:randalljohnson@centralchurch.com
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