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PENINSULA BIBLE CHURCH • 3505 MIDDLEFIELD ROAD • PALO ALTO, CA 94306 • 650/494-3840 Please print neatly in ink. Leave blank anything not applicable.
STUDENT’S NAME: ____________________________________ BIRTHDATE:____________ AGE: _________STUDENT’S ADDRESS: ________________________________ CITY: ___________________ ZIP: __________STUDENT’S EMAIL:______________________________________________________ GRADE FOR 2013-14:______ STUDENT’S CELL Phone? ( __ __ __) ______________________ Parents' or Guardians' Names:Dad: ________________________________________ Mom: ______________________________________ HOME Phone: ( __ __ __) ______________________ Different HOME Phone? ( __ __ __) ______________________ CELL Phone: ( __ __ __) ______________________ CELL Phone: ( __ __ __) ______________________ WORK Phone: ( __ __ __) ______________________ WORK Phone: ( __ __ __) ______________________ Local Emergency Contact (in case parent(s) are out of town):Name:_________________________________________ PHONE: ( __ __ __) _____________________________ HEALTH HISTORY (Please explain any condition we should be aware of ):________________________________________________________________________________________________________________________________________________________Al ergies (insect stings, drugs, food, etc.): _____________________________________________________________________Normal Treatment: _____________________________________________________________________________________Additional food restrictions? _________________________________________________________________________________Name & Dosage of Medications Currently taking:_______________________________________________________________ ________________________________________________________________________________________ Blood Type:_______Any other conditions (heart condition, diabetes, asthma, epilepsy, etc.): _________________________________________________________________________________________________________________________________________________________Last Tetanus Shot:____/____/___ Any swimming restrictions? yes____no____ Any activity restrictions? yes____no____ What restrictions? __________________________________________________________________________________________If your boy(s) may have an analgesic (pain med) in the event of an injury or ache, initial which ones: ______ Acetaminophen such as Tylenol ______ Ibuprofen such as Advil and Motrin ______ Naproxen such as Aleve.
INSURANCE Our church's insurance is only secondary insurance. If you have medical insurance, your carrier wil be bil ed for medical charges in the case of il ness or injury while participating in activities or on the church premises.
Medical Insurance Company Name:________________________________________________ Phone #_______________________________Group and Policy Numbers:_______________________________________________ Address:_______________________________________LIABILITY RELEASEEvery activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, you agree to assume and accept all risks and hazards inherent in church-related social and sport activities including transportation to and from activities. You also agree that you wil not hold Peninsula Bible Church or its employees or volunteers liable for damages, losses or injuries to the person named on this form. You understand that this form and your signature are for both medical and liability release.
MINOR'S LIABILITY RELEASEI give permission for my child,____________________________________, to participate in al activities as part of the Battalion ministry of Peninsula Bible Church of Palo Alto, California. As parent or legal guardian of said minor, I accept ful responsibility for my child's participation in such activities including transportation to and from any location in connection with PBC events. I wil assume ful responsibility for any medical costs incurred in the event of an accident or other incident requiring medical treatment. I release PBC and Battalion leaders from any liability. In the event of an emergency in which my child is in need of immediate hospitalization, medical attention or surgery, and after reasonable efforts have been made to contact me or my spouse and we cannot be located for the purpose of consenting thereto, consent for the emergency attention may be given by any person standing loco parentis to my child. It is understood that my child wil obey al regulations and fol ow instructions of the leaders. I agree to pay any expenses including the cost of my son/daughter being sent home if discipline is deemed necessary. The above Liability and Medical Release covers any and al activities sponsored byor associated with Peninsula Bible Church.
Parent/Guardian Signature:____________________________________________________________ Date:______________________________Print Name:_____________________________________________________________________________________________________________

Source: https://www.pbc.org/system/files/102/original/MedicalRelease.pdf

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