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Please complete the following Medical Release.  Directions to the event are provided below.  See you there!

Name *
Name
Birthdate *
Birthdate
Address *
Address
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 Phone *
Emergency Contact #1 Phone
Emergency Contact #2 *
Emergency Contact #2
Emergency Contact #2 Phone *
Emergency Contact #2 Phone
Family Physician Phone *
Family Physician Phone
List any allergies to foods, drugs, insects, vegetation or others.
Parent or Guardian Signature *
Parent or Guardian Signature
PERMISSION FOR TREATMENT In the event that I/we the undersigned parent(s) or guardian(s) of ___________________________________, a minor, cannot be reached, I/we do hereby authorize adult workers for the youth group of The Quest Church, Royse City, TX as agent(s) for the undersigned, to consent to any examinations, x-rays, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is rendered under the general or special supervision of any physician, surgeon, anesthesiologist, dentist, or other qualified medical personnel licensed under the provinces of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. RELEASE OF LIABILITY I/We, the undersigned, do hereby release, remise and forever discharge The Quest Church and all adult workers for the TeenQuest Ministry of The Quest Church from any and all claims, demands, actions or cause of action, past, present, or future arising out of any damage or injury while participating in a church sponsored trip or event. PHOTO/AUDIO/WEB RELEASE Further, I/We consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the participant during their participation in any activity, event, or trip to be used, distributed, or shown as the church sees fit including but not exclusive to: slide shows, church web site, print media and local newspapers. (When used in the public realm identifying information will be used responsibly e.g. names will not be attached to specific pictures on the church web site).
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