Covenant Fellowship Church Medical Disclosure Form


Health History (check conditions and describe below, list the year for each illness). ___ ADD/ADHD. ___ Anemia ... ___ Joint or Muscle Pain. ___ Knee ...

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Covenant Fellowship Church Medical Disclosure Form Household Information Family Name: _____________________________________________________________________ Address:_________________________________________________________________________ City: ____________________________________________ State: ________ Zip Code: __________ Email Address (for medical questions): _________________________________________________ Phone Number: ___________________________________________________________________ Emergency Contacts and Information Parent or Guardian Name: __________________________________________________________________ Mobile Phone: _____________________________ Secondary phone number: _________________________ Alternate Contact: _________________________________________________________________________ Mobile Phone: _____________________________ Secondary phone number: _________________________ Primary Care Physician:_____________________________ Office phone number: _____________________ Insurance Carrier: __________________________________ Policy Number: _________________________ Insurance Carrier’s Phone Number: ___________________________________________________________

By signing below, I acknowledge that I have completed the following Medical Disclosure Form accurately, truthfully, and to the best of my knowledge. I further warrant and represent that if any of the information contained in this form changes ​at any time​, I will immediately provide Covenant Fellowship Church with such updated information. I acknowledge that the program will handle medication as described and that such information on this form will be shared with staff on a need-to-know basis. Parent or Guardian Name: __________________________________________________________________ (Please print) Parent or Guardian Signature: _______________________________________________ Date: __________ Received by: _____________________________________________________________ Date: __________ (Authorized CFC Staff member)

Participant Information (Please PRINT in ink) Student #1’s Full Name: ________________________________________ Age: _____ Gender: M / F Height: ____________ Weight: _________Date of Birth ____ / ____ / ____ Allergies Medication(s): ____________________________________________________________________________ Bee or Insect Stings: _________________ Treatment __________________ Intolerance _ ​ __​Anaphylaxis _ ​ __ Foods (list): _________________________ Treatment __________________ Intolerance _ ​ __​Anaphylaxis _ ​ __ Asthma​ ……………………………………..Yes ​___ ​ No ​___ If YES, will you child carry a rescue inhaler during the program? Yes ​___ ​ No ​___ If YES, does your child need staff help to use that rescue inhaler? Yes​___ ​ No ​___ If YES, what triggers your child’s asthma? ______________________________________________________ Activity Restrictions: _____________________________ Physical Handicaps: _________________________ Dietary Restrictions?: ______________________________________________________________________ Any limiting fears?: ________________________________________________________________________ Date of Last Physical Exam: ____ / ____ / ____ Date of Last Tetanus: (DPT) ____ / ____ / ____ Date of Last (MMR): ____ / ____ / ____ Health History (check conditions and describe below, list the year for each illness) ___ ADD/ADHD ___ Anemia ___ Appendicitis ___ Asthma ___ Back Pain or Injury ___ Bedwetting ___ Bleeding/Clotting Disorder ___ Blood Pressure (high/low) ___ Bronchitis ___ Chicken Pox ___ Colitis ___ Concussion/Head Injury ___ Corrective Lenses (eyes) ___ Cramps, severe ___ Cystitis ___ Dental Appliances

___ Diabetes ___ Diarrhea/Constipation ___ Dislocations ___ Eating Disorder ___ Emotional/Behavioral Issue ___ Epilepsy or Convulsions ___ Fainting or Dizziness ___ Fractures (broken bones) ___ Frequent Ear Infections ___ Gall Bladder ___ Hay Fever ___ Heat Stroke or Exhaustion ___ Heart Disease or Defect ___ Hepatitis A, B, or C ___ Hernias ___ HIV Positive

___ Joint or Muscle Pain ___ Knee Injury or trouble ___ Measles ___ Migraine Headaches ___ Mononucleosis ___ Motion Sickness ___ Pneumonia ___ Rheumatic Fever ___Skin Condition or rashes ___ Sleepwalking ___ Sprains or strains ___ Tuberculosis ___ Tumor or Growth ___ Ulcer ___ Urinary Difficulties ___ Venereal Disease

Name any injuries, illness, or disabilities not mentioned and the year of occurrence: ________________________________________________________________________________________ Hospitalizations or surgeries (list below or attach on separate paper the dates, reasons, hospital names and locations): ________________________________________________________________________________________ Does the participant have any physical, emotional, mental, or physiological limitations that would affect your participation in this event? Yes​___ ​ No ​___ If yes, please fully describe such conditions or limitations below: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Participant Information (Please PRINT in ink) Student #2’s Full Name: ________________________________________ Age: _____ Gender: M / F Height: ____________ Weight: _________Date of Birth ____ / ____ / ____ Allergies Medication(s): ____________________________________________________________________________ Bee or Insect Stings: _________________ Treatment __________________ Intolerance _ ​ __​Anaphylaxis _ ​ __ Foods (list): _________________________ Treatment __________________ Intolerance _ ​ __​Anaphylaxis _ ​ __ Asthma​ ……………………………………..Yes ​___ ​ No ​___ If YES, will you child carry a rescue inhaler during the program? Yes ​___ ​ No ​___ If YES, does your child need staff help to use that rescue inhaler? Yes​___ ​ No ​___ If YES, what triggers your child’s asthma? ______________________________________________________ Activity Restrictions: _____________________________ Physical Handicaps: _________________________ Dietary Restrictions?: ______________________________________________________________________ Any limiting fears?: ________________________________________________________________________ Date of Last Physical Exam: ____ / ____ / ____ Date of Last Tetanus: (DPT) ____ / ____ / ____ Date of Last (MMR): ____ / ____ / ____ Health History (check conditions and describe below, list the year for each illness) ___ ADD/ADHD ___ Anemia ___ Appendicitis ___ Asthma ___ Back Pain or Injury ___ Bedwetting ___ Bleeding/Clotting Disorder ___ Blood Pressure (high/low) ___ Bronchitis ___ Chicken Pox ___ Colitis ___ Concussion/Head Injury ___ Corrective Lenses (eyes) ___ Cramps, severe ___ Cystitis ___ Dental Appliances

___ Diabetes ___ Diarrhea/Constipation ___ Dislocations ___ Eating Disorder ___ Emotional/Behavioral Issue ___ Epilepsy or Convulsions ___ Fainting or Dizziness ___ Fractures (broken bones) ___ Frequent Ear Infections ___ Gall Bladder ___ Hay Fever ___ Heat Stroke or Exhaustion ___ Heart Disease or Defect ___ Hepatitis A, B, or C ___ Hernias ___ HIV Positive

___ Joint or Muscle Pain ___ Knee Injury or trouble ___ Measles ___ Migraine Headaches ___ Mononucleosis ___ Motion Sickness ___ Pneumonia ___ Rheumatic Fever ___Skin Condition or rashes ___ Sleepwalking ___ Sprains or strains ___ Tuberculosis ___ Tumor or Growth ___ Ulcer ___ Urinary Difficulties ___ Venereal Disease

Name any injuries, illness, or disabilities not mentioned and the year of occurrence: ________________________________________________________________________________________ Hospitalizations or surgeries (list below or attach on separate paper the dates, reasons, hospital names and locations): ________________________________________________________________________________________ Does the participant have any physical, emotional, mental, or physiological limitations that would affect your participation in this event? Yes​___ ​ No ​___ If yes, please fully describe such conditions or limitations below: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Participant Information (Please PRINT in ink) Student #3’s Full Name: ________________________________________ Age: _____ Gender: M / F Height: ____________ Weight: _________Date of Birth ____ / ____ / ____ Allergies Medication(s): ____________________________________________________________________________ Bee or Insect Stings: _________________ Treatment __________________ Intolerance _ ​ __​Anaphylaxis _ ​ __ Foods (list): _________________________ Treatment __________________ Intolerance _ ​ __​Anaphylaxis _ ​ __ Asthma​ ……………………………………..Yes ​___ ​ No ​___ If YES, will you child carry a rescue inhaler during the program? Yes ​___ ​ No ​___ If YES, does your child need staff help to use that rescue inhaler? Yes​___ ​ No ​___ If YES, what triggers your child’s asthma? ______________________________________________________ Activity Restrictions: _____________________________ Physical Handicaps: _________________________ Dietary Restrictions?: ______________________________________________________________________ Any limiting fears?: ________________________________________________________________________ Date of Last Physical Exam: ____ / ____ / ____ Date of Last Tetanus: (DPT) ____ / ____ / ____ Health History (check conditions and describe below, list the year for each illness) ___ ADD/ADHD ___ Anemia ___ Appendicitis ___ Asthma ___ Back Pain or Injury ___ Bedwetting ___ Bleeding/Clotting Disorder ___ Blood Pressure (high/low) ___ Bronchitis ___ Chicken Pox ___ Colitis ___ Concussion/Head Injury ___ Corrective Lenses (eyes) ___ Cramps, severe ___ Cystitis ___ Dental Appliances

___ Diabetes ___ Diarrhea/Constipation ___ Dislocations ___ Eating Disorder ___ Emotional/Behavioral Issue ___ Epilepsy or Convulsions ___ Fainting or Dizziness ___ Fractures (broken bones) ___ Frequent Ear Infections ___ Gall Bladder ___ Hay Fever ___ Heat Stroke or Exhaustion ___ Heart Disease or Defect ___ Hepatitis A, B, or C ___ Hernias ___ HIV Positive

___ Joint or Muscle Pain ___ Knee Injury or trouble ___ Measles ___ Migraine Headaches ___ Mononucleosis ___ Motion Sickness ___ Pneumonia ___ Rheumatic Fever ___Skin Condition or rashes ___ Sleepwalking ___ Sprains or strains ___ Tuberculosis ___ Tumor or Growth ___ Ulcer ___ Urinary Difficulties ___ Venereal Disease

Name any injuries, illness, or disabilities not mentioned and the year of occurrence: ________________________________________________________________________________________ Hospitalizations or surgeries (list below or attach on separate paper the dates, reasons, hospital names and locations): ________________________________________________________________________________________ Does the participant have any physical, emotional, mental, or physiological limitations that would affect your participation in this event? Yes​___ ​ No ​___ If yes, please fully describe such conditions or limitations below: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

COVENANT FELLOWSHIP CHURCH RELEASE/WAIVER OF LIABILITY AND INDEMNIFICATION AGREEMENT I am the parent or legal guardian of _________________________________ (“my child”), who is under 18 years old. In consideration for my child’s participation in the Vacation Bible School (“VBS”) of Covenant Fellowship Church (“CFC”), I affirm and agree with the following statements: 1. I voluntarily agree to allow my child to participate in VBS, and expressly assume any and all dangers, hazards, and risks associated with my child’s participation in VBS. 2. My child is physically sound and suffering from no condition, impairment, disease, or other illness that would hinder my child’s participation in VBS. It is my responsibility to ensure that my child follows any restrictions, prescriptions, or limitations that apply to his/her physical condition or state of fitness. 3. I understand that my child’s participation in VBS may include physical activity that requires strength, flexibility, and/or stamina, and that my child could become injured while participating in such activity, especially if he/she exceeds the limits that his/her body is capable of performing. 4. I will familiarize myself with any applicable VBS rules and abide by them. I understand that CFC retains the right to suspend or terminate my child’s participation in VBS if it believes that my child or I have failed to comply with VBS rules or instructions, or for any other reason in its sole discretion. 5. Except where such an exception is prohibited or limited by applicable law, except for any claims, actions, liability, and or/demands (“Claims”) that arise from, are caused by, or result from the gross negligence or willful misconduct of CFC and its employees, volunteers, independent contractors, agents, assignees, representatives and successors in interest (collectively, “Affiliates”), I hereby release, forever discharge, and agree to hold harmless CFC and its Affiliates from any and all Claims for bodily injury, property damage, wrongful death, loss of services, or otherwise, which may arise out of my child’s participation in VBS, which may hereafter accrue to me against CFC and/or its Affiliates. [OPTIONAL: This Release/Waiver is understood to also be in effect with respect to, and to include any persons who may be engaged in, the transportation, treatment or attending to, or accompanying me to facility for Medical Treatment on or off VBS property, on the same basis and terms as stated above.] I further agree to hold harmless and indemnify CFC and its Affiliates from any Claims resulting in any way from my acts or omissions. 6. I hereby give CFC and its Affiliates the irrevocable right to copy, display, publish, or otherwise use my child’s image in any form of media that now exists or may exist in the future, and give other permission to copy, display, publish, or otherwise use my child’s image, so long as CFC and/or its Affiliates determine that doing so supports or benefits CFC’s mission. 7. I agree that any dispute that I may have with CFC and/or its Affiliates regarding my child’s participation in VBS and/or this Release/Waiver shall be settled only by mediation, or if necessary, legally binding arbitration in accordance with the Rules of Procedure of the Institute for Christian Conciliation of Peacemaker Ministries, ​www.peacemaker.net​. I understand that the decision and/or award of an arbitrator may be entered in any court otherwise having jurisdiction and that such a decision and/or award shall be the sole remedy to any dispute and is non-appealable. 8. I recognize and fully understand and agree that in the event it becomes necessary for my child to receive medical treatment during my child’s participation in VBS, reasonable efforts will be made to

contact the persons listed on my child’s Medical Disclosure Form to obtain directions and authorization for such treatment. However, if the person(s) listed cannot be reached, I hereby authorize, direct, and give my full and complete permission to CFC and/or any Affiliates to seek medical treatment for my child, including selecting and authorizing medical professional(s) (including, but not limited to nurses, LPNs, PAs,paramedics, doctors, or dentists) to take such action as is deemed necessary by any attending medical professional. I further give my full and complete authorization to such medical professional to hospitalize, order injections, administer anesthesia, perform surgery, or secure additional necessary medical treatment for my child as necessary and/or appropriate under the circumstances as determined by the medical professional. I further certify that I am willing to assume the risk of any medical or physical condition that my child may have. I further understand and acknowledge that it is my duty to provide accurate and current information of such conditions on the Medical Disclosure Form. I recognize and fully understand that the insurance coverage listed on my Medical Disclosure Form will be used as the sole insurance coverage for my child in the event medical treatment is needed, and that I (or the responsible party for my insurance coverage) am solely and personally responsible for any payments or charge(s) not covered by such insurance. I further understand, acknowledge, and agree that no such insurance coverage is or will be provided for me by CFC. I understand and agree that if I do not currently have valid health insurance coverage, none will be provided for me by CFC, and that I (or the responsible party for my insurance coverage) am responsible for any and all costs associated with medical treatment that may be required as a result of my child’s participation in VBS. 9. Should any provision of this Release/Waiver be held to be void, invalid or inoperative, the remaining provisions of this Release/Waiver shall not be affected and shall continue in effect and the invalid provision shall be deemed modified to the least degree necessary to remedy such invalidity. I (WE), _______________________________, AM (ARE) THE PARENT(S) OF LEGAL GUARDIAN(S) OF __________________________________, A CHILD UNDER THE AGE OF 18 YEARS, AND I (WE) HAVE THE SOLE AND EXCLUSIVE RIGHT AND AUTHORITY TO ENTER INTO THIS RELEASE/WAIVER ON MY CHILD’S BEHALF AND TO GRANT THESE RIGHTS.

___________________________________ Parent/Guardian Signature

Name: _____________________________ Address: _____________________________ _____________________________ Email: _____________________________ Phone: _____________________________

___________________________________ Parent/Guardian Signature

Name: _____________________________ Address: _____________________________ _____________________________ Email: _____________________________ Phone: _____________________________