List medication/supplement currently being taken including dosage, frequency, and any special instructions (Please provide all medications in the original prescription or over-the-counter container with his/her name clearly written on it)
Permission for Medical Treatment, Photograph/Video, and Release and Indemnity
I am confident that the adult leaders and sponsors will take appropriate care of my child and every effort will be made for his/her safety. However, I understand that accidents do occur, and in the event of an emergency, every effort will be made to contact me. In the event of an emergency, I hereby grant permission to a representative of the Event organizer, staff member, or adult present, as agent for me, to obtain necessary medical attention in case of sickness or injury to my child as provided by the loco parentis clause of Virginia Code 54.1-2969, to give consent for any X-ray examination; medical, dental, or surgical diagnosis; emergency medical or surgical treatment; and hospital care for my child advised and supervised by a licensed physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I also agree to reimburse any expenses not covered by the Church’s insurance. I, the undersigned parent/guardian of said child, do hereby release, acquit, discharge, and covenant to hold harmless and indemnify One Community or affiliate for any and all claims, demands, damages, injuries, costs, suits, or causes of action, past, present, or future arising out of any accident or sickness, or treatment thereof, by me or my child while participating in any One Community Church or affiliate program, event, or activity.
I, the undersigned parent/guardian of said child, do hereby waive and release, indemnify, hold harmless and forever discharge One Community Church and any affiliate, camp, or Event host organizations and their agents, employees, and volunteers from any and all claims, expenses, demands, actions or causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or in equity, that I ever had or may have, arising from, out of, or in any way related to my participation and/or the participation of my child in any events, transportation to and from, and/or any other activities related to One Community Church, provided that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful, or wanton misconduct.
I understand that as a participant, my child or I may be photographed or videotaped during normal ministry or event activities and these photos/videos may be used in promotional materials. I hereby grant Thomas Road permission to use of my and/or my child’s name and to use, copy, or modify such images or recordings without restriction and release the photographer and One Community from all claims and liability relating to these images and recordings.
I have read, understood, and fully agree to the above and hereby verify that the above information is true and accurate to the best of my knowledge. Parent/Guardian agrees to provide transportation for child if he/she is found in violation of any of the General Rules.