Activity Waiver & Medical Release

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Medical Information Please complete every block on this page. If the area does not apply, mark n/a
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Name of Student's physician(*)
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Activity Waiver and Release
I certify that I am the parent or guardian (listed above) of the child (listed above,hereafter the “Minor Child”). My signature as the parent or guardian of the above named minor child indicates my consent to the following:

I hereby consent to allow my Minor Child to participate in the activity or activities of Hanover Community Church (“HCC” or the “Church”) from August 2018 – August 2019 (hereafter the “Activity”) including any transportation or travel that may be necessary to and from the Activity venue, including if the Activity is outside the Commonwealth of Pennsylvania. I represent that the Minor Child is in good health and is physically able to participate in the Activity. I further represent that the information supplied on this Release is accurate, including the medical information.

I recognize that there are risks involved in participating in this Activity and hereby assume all risk of injury, harm, damage, or death to my Minor Child in connection with his/her participation in this Activity. It is understood that every reasonable precaution will be taken for the safety and well-being of my child and to the fullest extent permitted by law, I release HCC, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my Minor Child while participating in the Activity and agree to release and hold harmless HCC, its trustees, officers, directors, employees, agents and representatives from and against any and all claims, liabilities, suits, actions, administrative proceedings, costs, fines, losses, penalties and damages, whether brought by myself, a person acting on behalf of my Minor Child or my Minor Child’s estate, including, without limitation, reasonable attorneys’ fees, arising out of, or resulting from my Minor Child’s participation in the Activity. I agree to indemnify HCC for any liability due to my Minor Child’s participation in the Activity.

In case of a medical emergency involving my Minor Child, I understand that hospital policy requires parental permission before treatment. I understand that HCC will contact me if care is needed, but in the event I cannot be reached in an emergency, I hereby grant HCC a limited medical power of attorney as follows:

I give permission to the physician selected by a HCC representative to hospitalize and secure proper treatment for my Minor Child. I have provided HCC with a medical information form for my Minor Child including emergency contact information. I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician or surgeon for my Minor Child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist for my Minor Child. I further agree to pay all charges for the dental, medical, or hospital care or treatment and to reimburse HCC for any charges it incurs in care of my Minor Child. As parent or legal guardian of my Minor Child, I am responsible for the health care decisions of my Minor Child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my Minor Child is legally sufficient and that no consent from any other person is required by law.

This form may be signed by digital or electronic means. In accordance with the Pennsylvania Electronic Transactions Act and the Electronic Signatures in Global and National Commerce Act, I agree that any digital or electronic signature that I apply to this form shall have the same binding effect as my handwritten signature to the fullest extent permitted under the law."

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