Youth Ministries Medical and Liability Release

REQUIRED FOR ALL 6TH-12TH GRADE STUDENTS AND ADULTS ATTENDING A VINTAGE CHURCH LA EVENT

KAYAKING TRIP AUGUST 10TH

Date: 08/10/2019

Full Name: DOB:

Age: Gender:

Address: 2469 Westridge Road, Los Angeles, CA 90049

Phone #: Email:

School: Homeschool Current Grade: 10

Parent or Guardian Name: Di-aan Gamaroff

Phone #: 9147040713
Email: [email protected]

Parent or Guardian Name:

Phone #: Email:

In an Emergency, if parent/guardian cannot be reached, please notify:

Michael Gamaroff
Name:
Father
Phone #: 917 678-2017 Relation:
Health History

Drug Allergies Food Allergies Insect Sting Allergies

Diabetes Frequent Colds Heart Condition

Chronic Asthma Physical Handicap Frequent Upset Stomach

Environmental Allergies Epilepsy/Nervous Disorder Other

If any of the above are check, please give detail (i.e. treatment or allergic reactions):

Name, Dosage, and Frequency of ALL Medications taken currently:

Minor administers own medication? Yes No

Adult administers medication? Yes No

If student requires aspirin or other medications, may an adult counselor administer it?

Yes No

Aspirin substitute? (specify)

Health Insurance? Yes No Name of Insurance: Anthem Blue Cross

Expiration Date: Insurance Policy #:JQU563M97752 Group #: J77301

Insurance Company Address:

Doctor Name: Phone #:

2015
Date of Last Tetanus Shot?

Will you allow a blood transfusion? Yes No Blood Type (if known)

Any swimming or activity restrictions? Yes No

If yes, explain:

Contact Lenses? Yes No

 Vintage Church LA
Medical and Liability Release

If you or your child requires medical attention for pre-existing injuries or illnesses, please provide the
necessary information to give you or your child the prescribed medical attention during an activity or trip. In
the case of illness or injury, while you or your child is at an activity or trip, your medical insurance will be billed
for medical charges. Any updates to your insurance policy must be provided to Youth Ministries.

Authorization of Consent to Treatment:

(I) (We), the undersigned, parents(s) of______________________________________________________,

(self or a minor), do hereby authorize Vintage Church LA youth ministry leaders as agent(s) for the
undersigned to consent to any dental care, x-ray examination, anesthetic, medical or surgical diagnosis or
treatment, and hospital care which is deemed advisable by, and is rendered under the general or specific
supervision of, any physician and surgeon licensed under the provision of the Medical Practice Act, whether
such diagnosis or treatment is rendered at the office of said physician or at a hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care
being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give
specific consent to any and all such diagnosis treatment or hospital care which the aforementioned physician
in the exercise of his best judgment may deem advisable. This form is for any and all events, projects,
ministries, small groups, or trips involving Vintage Church LA. It is understood that this authorization is given in
advance of any specific diagnosis, treatment, or hospital care being required. The above authorization is given
pursuant to the provisions of Section 25.8 and 34.6 of the Civil Code of California and shall remain effective
through the above-named minor’s graduation from high school, unless sooner revoked in writing delivered to
said agent(s).

______________________________________________________________
Parent/Guardian Signature (Student Signature if over age 18)

______________________________________________________________
Di-aan Gamaroff

Print Name

_______________________________________________
08/10/2019

Date

_______________________________________________
Mother

Relationship to Student
 Release of Vintage Church LA:

______________________________________________________(self/parent’s
Di-aan Gamaroff
name) shall indemnify, hold
free and harmless, assume liability for, and defend Vintage Church LA, its agents, servants, employees,
officers, and directors from any and all costs and expenses including but not limited to, medical costs,
attorney’s fees, reasonable investigative and discovery costs, court costs, and all other sums which Vintage
Church LA assertion of liability, or any claim or action founded thereon, arising or alleged to have arisen out
of______________________________________________________(self/child’s name) use of real or personal
property belonging to Vintage Church LA, as agents, servants, employees, officers, and directors, or by action
or omission by_____________________________________________________(self/child’s name). Also,
Vintage Church LA reserves the right to use any audio, video, and/or photography of guests and/or campers
participating in Vintage Church LA facilitated events.

IT IS ALSO ACKNOWLEDGED THAT IF YOU OR YOUR CHILD HAS TO RETURN HOME EARLY FOR DISCIPLINE
VIOLATIONS, IT WILL BE AT YOUR OR THE PARENT/GUARDIAN’S EXPENSE.

By signing this document, I acknowledge that I have had sufficient opportunity to read this entire document. I
have read and understood it and agree to be bound by its terms.

______________________________________________________________
Parent/Guardian Signature (Student Signature if over age 18)

______________________________________________________________
Di-aan Gamaroff

Print Name

_______________________________________________
08/10/2019

Date

_______________________________________________
Mother

Relationship to Student