Arrow Liability Release & Medical Authorization


Arrow Release

Liability Release and Medical Authorization

Parent/Guardian Fullname
Parent/Guardian Fullname
Home Address
Cell Phone
Emergency Phone  
Medical Insurance Carrier   Policy Number   Insured's Name  

 

We do hereby release, absolve, and hold harmless the directors, coaches, and adult leaders of Home Run Ministries, Inc. (DBA Arrow Christian Academy) from any and all liability for all losses, damages, or injuries occurring as a result of our child’s presence or participation in any sponsored activities. We also absolve and hold harmless any facility and its directors that Home Run Ministries is using for its activities. We further agree to make or cause to be made, by assignment of third party benefits or otherwise, full and complete payment for examination, treatment, or hospital care required in the case of a medical emergency. Furthermore, we hereby authorize, in the event of an injury, any director, coach, medical attendant, or adult leader of Arrow Christian Academy to consent to emergency medical treatment for our child when we cannot be contacted to give consent. Such medical treatment may include, without limitation, x-ray examination, anesthetic, medical, surgical examination or treatment, and general hospital care. Except as noted below, this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of a director, coach, or adult leader of Arrow Christian Academy to give specific consent to any and all such examination, treatment, or hospital care.

Except as indicated below, we specifically give our consent for first aid treatment with bandages, antibiotic ointment, hydrogen peroxide, acetaminophen and/or ibuprofen. Listed below are any prescription medications that our child takes on a regular basis.

Students Name:  
Treatment Exceptions:  
Medications:  
Allergies:

 

We hereby verify that we understand and accept the terms of this Liability Release and Medical Authorization. 

 

 that we will notify Arrow Christian Academy if our student has a change in Medications or Allergies.

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Signature Certificate
Document name: Arrow Liability Release & Medical Authorization
lock iconUnique Document ID: c4ba427a8e25d8e031825b3149e0006753770515
Timestamp Audit
March 18, 2019 8:44 pm CDTArrow Liability Release & Medical Authorization Uploaded by Rebecca Zappasodi - Rebecca@arrowchristian.com IP 173.71.38.222