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Mountainous Landscape by the Sea
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Gospel of John - Face to Face with Christ

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MACCSR English Program 2027 Medical Release Form

This church strives to be a safe, friendly space for all children, college students, and adults. In order to maintain a safe environment, we ask for you to fill out this medical form. 


Disclaimer: MACCSR does not provide insurance coverage for this event.  If you have medical insurance, your carrier or you will be billed for medical charges in the case of illness or injury while the participant is in an MACCSR activity. You agree to pay all fees and costs arising from this action to obtain medical treatment.

Participant Information
Date of Birth
Month
Day
Year
Education/Career
Middle School
High School
College/Adult
Emergency Contact 1

Recommendation: Parent(s)/Guardian(s) to participant

Recommendation: Parent(s)/Guardian(s) to participant

Recommendation: Parent(s)/Guardian(s) to participant

Recommendation: Parent(s)/Guardian(s) to participant

Emergency Contact 2
Physician Information
Special Needs & Health Concerns
Insurance Information
Is the participant covered by family medical / hospitalization insurance?
Family Medical Insurance
Hospitalization Insurance
Participant is not covered by any form of insurance
Authorization of Consent to Treatment

Medical Release: I, the undersigned parent(s) and/or legal guardian (or participant if legal age), do hereby authorize MACCSR and its leaders, employees, volunteers, and agent to secure medical treatment for this person (me) in case of illness or accident for which they feel requires professional medical attention. I hereby, in advance, give permission to medical personnel selected by the MACCSR staff to secure proper treatment for, hospitalize, and order injection, anesthetics or surgery for my child (me), in my absence. It is understood that reasonable efforts will be made to contact me/us prior to obtaining such care. I fully understand the consequences of the foregoing statement and sign this AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE knowingly, freely, and willingly.


Liability Release: Every activity sponsored by MACCSR is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. In consideration of MACCSR permitting my child / young adult to participate in this event, I, on behalf of myself and my heirs, representative, directors, employees, volunteers, agents, insurer, and/or successors forever waive any and all claims in law or equity, demands, suits, or liabilities, including claims for personal injury or loss of any kind, based upon or in any way arising out of and/or relating to my child’s participation in the event, whether known or unknown and including any and all damages caused by MACCSR’s negligence, gross negligence and/or intentional acts. I further agree to indemnify and hold harmless MACCSR and its leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and program, or as a result of injury or illness of my child during such activities.

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