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Articles of Faith



The Articles of Faith

ADULT MEDICAL AUTHORIZATION AND RELEASE FORM


ADULT MEDICAL AUTHORIZATION AND RELEASE FORM

Name:

Ward:

EMERGENCY

In case of emergency, please contact the following person or persons: Name(s) & Telephone number(s):

MEDICAL TREATMENT

I authorize and approve the providing of medical and dental treatment as may become reasonably necessary due to accident or injury during the course of the activities. The name and telephone number of my physician or medical group is:

Name(s):

Telephone number(s):

INSURANCE AND INDEMNIFICATION

I agree to provide medical insurance coverage for my participation in the activities. My insurance carrier and policy number is:

Name of Insurance Carrier:

Policy Number:

DISCLOSURE OF MEDICAL PROBLEMS AND CONCERNS

I have the following medical problems, concerns, allergies, and medication requirements:

I

use an inhaler.

PERMISSION FOR USE OF OVER-THE-COUNTER MEDICATIONS Below is a list of over-the-counter medications which may be available for use at the Activities. All medications will be dispensed at the discretion and judgment of adult leadership. I can use the following over-the-counter medications:

 

 

HEALTH HISTORY

If you currently suffer from, or have experienced any of the following conditions within the past year, please check the condition below:

 

     

 

Explain:   

If you marked yes to any of the above items, you must fill out a Medical Release Form and have it completed by a medical doctor; you cannot participate without it.

The Medical Release Form is available from your Stake YM/YW leaders.

TERM OF AUTHORIZATION AND RELEASE

This Authorization and Release shall remain in full force and effect to and through December 31 of the year following the date thereof.

SEVERABILITY

If any part or portion of this Authorization and Release is unenforceable for any reason, the remainder shall continue in full force and effect.

RELEASE OF LIABILITY

I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE CHURCH, ITS AGENTS AND REPRESENTATIVES, FROM ANY AND ALL LIABILITY, HARM, DAMAGES, COSTS, INCLUDING ATTORNEY FEES, ARISING FROM MY CHILD’S PARTICIPATION IN CAMP KOLOB, I AGREE NOT TO BRING ANY LEGAL ACTION OR CLAIM FOR DAMAGES AGAINST THE 3 CHURCH, ITS AGENTS AND REPRESENTATIVES, BY REASON OF ANY INJURY TO MY CHILD, REGARDLESS OF CAUSE OR FAULT ARISING FROM MY CHILD’S PARTICIPATION. I UNDERSTAND THE TERMS OF THIS AUTHORIZATION AND RELEASE AND GIVE MY CONSENT TO IT.

Dated:

Nameof Participant:

Leave this empty:

HB LDS Stake https://hbstake.org
Signature Certificate
Document name: ADULT MEDICAL AUTHORIZATION AND RELEASE FORM
Unique Document ID: 7505311b75eb50e61ebdbe1e4d07ed02ea866881
Timestamp Audit
2017-07-01 11:56:02 PSTADULT MEDICAL AUTHORIZATION AND RELEASE FORM Uploaded by Trisha Templin Templin - trisha.templin@gmail.com IP 47.153.147.121

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