<p> VAN DYKE CHURCH MEDICAL RELEASE FORM</p><p>Participant’s Name: ______Grade:____ Last First </p><p>Home Phone: Birthdate: Month Day Year</p><p>Address: Street City State Zip</p><p>Parent/Guardian: 1. Cell Phone: Name Cell Phone Carrier: ______</p><p>2. Cell Phone: Name Cell Phone Carrier: ______</p><p>→ Medications you cannot take: </p><p>→ Allergies/special health problems or concerns: </p><p>→ Current tetanus shot? ____ Yes ____ No (We encourage you to get one prior to any event)</p><p>Insurance Information</p><p>Insurance Company: </p><p>Policy No. Company’s Phone: </p><p>Policy Holder’s Name: </p><p>Doctor’s Name: Doctor’s Phone: </p><p>In the event of an emergency or non-emergency situation in which medical treatment is required, every reasonable effort will be made to contact the person(s) listed on this form. If unsuccessful in contacting the person(s) listed, consent/permission is given for treatment by competent medical personnel. Further, I give authorization to Van Dyke Church Staff and other adult volunteers to hospitalize, secure proper treatment for and to order injection, anesthesia, surgery, etc. (under recommendation of qualified medical personnel). I also agree that my insurance will be used for such medical care, and I am aware that I may be billed by the medical provider for any medical treatment not covered by my insurance.</p><p>Signature of Parent/Guardian Relationship Date Over → Medical Consent</p><p>In the event of an emergency or non-emergency situation in which medical treatment is required, every reasonable effort will be made to contact the person(s) listed on this form. If unsuccessful, consent is given for treatment by competent medical personnel. Further, I give the Van Dyke Church Staff and Leaders authorization to hospitalize, and or proper medical treatment, to order injection, anesthesia, surgery, etc. (Under recommendation of qualified medical personnel.) I also agree that my insurance will be used for such medical care, and I am aware that I may be billed by the medical provider for any medical treatment not covered by my insurance.</p><p>______(Guardian) _July____/__13___/ _2014_ (Date)</p><p>______(Relationship)</p><p>Participation Consent</p><p>I ______give permission for ______to attend this and any event sponsored by or attended by the Van Dyke Church. I give my permission for use of photography taken of my child to be used in promotional literature or on the screen in during the event.</p><p>Signature: ______Relationship: ______Date: 7/13/2014</p><p>Notary</p><p>Before me appeared this day: July 13, 2014 ______(guardian)</p><p>Who is personally known to me or has produced ______(ID#) As identification and who executed the foregoing instrument for the purpose therein expressed.</p><p>Notary: ______</p><p>Commission Expires: ______/______/______(seal)</p><p>Camp Rules & Conduct (Must be signed by child attending camp—no exceptions) In all events under the sponsorship of Van Dyke Church, I will act as a representative of Van Dyke Church. I am responsible for my actions. I understand the camp rules:</p><p>Participants who are unable to carry out these guidelines will be spoken to by an authority figure. Violation of the above guidelines will result in disciplinary action to be determined by the adult supervisor.</p><p>I ______(child’s signature) have read and understand the rules and conduct code. I agree to follow the rules at all times. (Parents: Please help your child be aware of the value of their signature.)</p>