MIDDLE SCHOOL

Event Details

Name of Activity

Activity Date

Child Details

Name of Child

Address of Child

City of Child

State of Child

Date of Birth of Child

Allergies to Medication

Current Medications

Any Medical Conditions

Parent/Guardian Details

Name of Parent/Guardian

Parent/Guardian Address

Parent/Guardian City

Parent/Guardian State

Parent/Guardian Phone Number

Secondary Emergency Contact

Name

Street Address

Cell Phone Number

Agreement

The undersigned parent(s)/guardian(s) of the above minor-age child hereby gives consent to Treasure Valley Baptist Church, Inc ("TVBC"), and its agents, volunteers, and employees, etc., to act on my/our behalf in obtaining any medical treatment or care of any nature for said child and I/we authorize any medical person or entity to rely on this authorization. I/we agree to be solely liable and responsible for the costs of such treatment or care. I/we release TVBC, and its agents, volunteers, and employees, etc., from any liability of any nature whatsoever relating to the above activities. This release is full, complete, and absolute, except to the extent limited by Idaho law. I/we understand that this release and authorization is an absolute prerequisite to my/our child participating in this special activity and that it is retroactive to the first such participation even if signed later. I/we give permission to have my/our child participate in all activities connected with this special activity until this permission is revoked in a writing actually delivered to TVBC.

THIS IS A LEGAL FORM - PLEASE READ AND UNDERSTAND THIS FORM BEFORE SIGNING IT

Parent/Guardian Signature