MINOR LIABILITY AND MEDICAL RELEASE Community Covenant Church

2700 El Rancho Drive, Santa Cruz 95060 Phone: 831.438.4276 office@ccsv.org

Masterpiece Vacation bible camp July 10 – July 13, 2017

HEALTH INSURANCE: Our church’s insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while participating in the camp. Medical Insurance Company Name: Click here to enter text. Phone: Click here to enter text. Policy # Click here to enter text.	Subscriber’s Name: Click here to enter text. Child’s name: Click here to enter text.age:Click here to enter text.	birthdate: Click here to enter text. address:Click here to enter text.	male ☐ female ☐ city: Click here to enter text.	state:Click here to enter text.	zip: Click here to enter text. school/grade attending Fall 2017:Click here to enter text. Parents’ or Guardians’ Names: Click here to enter text. Best contact #Click here to enter text.: Email: Click here to enter text. Local contact other than yourself if you cannot be reached in the event of an emergency: Name:Click here to enter text. Phone:Click here to enter text. Relationship to Minor: Click here to enter text. HEALTH HISTORY: Any allergies/health concerns we should know about? _Click here to enter text. MINOR’S MEDICAL RELEASE In the event of an emergency where I cannot be reached, I give permission for the adults in charge at the Masterpiece Vacation Bible Camp to secure the services of a licensed physician to provide necessary care for my child’s well-being. You understand that this form and your signature is for medical and liability release. DATE: Click here to enter text. SIGNATURE: Click here to enter text. LIABILITY RELEASE It is your intention, as the parent or guardian of the minor listed on this form to exempt and relieve Community Covenant Church and its employees or volunteers from liability for personal injury, property damage and wrongful death caused by any act of negligence on the part of CCC and its employees and volunteers. Who, besides parent/guardian above, may pick your child up from camp? Click here to enter text. Please mail in or scan/email one form for each child you are registering.