Medical Release

Your name *

Email address *

Names of ALL minors in your household this medical information applies to *

If contact information or insurance information is different, please fill out this form again for the child(ren) that it is different for.

Emergency Contact Name *

First and last name please!

Emergency Contact Phone *

In case of an emergency, contact my student's doctor. *

In case of an emergency, treat a nearest available hospital a the discretion of event leadership. *

In case of an emergency, treat at a specific hospital. *

Hospitalization insurance company *

Insurance policy number *

Insurance group number *

Travel Agreement *

I understand that any Dawson Discipleship (Grades 1-12) event could involve travel away from the Dawson campus and/or outdoor or other common-risk activities. I am aware that certain risks and dangers exist or may occur during such activities, including travel. I hereby consent to my student’s participation in these events and agree to assume all the risks related to such participation.

I agree

Liability Release *

I hereby agree to release, and to hold harmless, Dawson Memorial Baptist Church and its agents and employees from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my student during and/or as a result of participation in these or other activities related to any Dawson sponsored activity or trip.

I agree

Publication Release *

I give my consent for Dawson Memorial Baptist Church to use the name, photo of, and or video of my child on the Dawson website or publications.

Yes

Electronic Signature *

I have carefully read and I understand the foregoing release. I sign this release of my own free act. I understand that this is a legally binding agreement.

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