Terms and Conditions
Creation Explorers
Physical Education Release Form
Family Medical Information
Doctor Name/ Phone
_________________________________________/______________
Dentist Name/ Phone
_________________________________________/______________
Emergency Contact Name/Phone
(to be contacted only if parent is not able to be reached)
_________________________________________/______________
Terms and Conditions
1) I understand that my child/children will participate in physical activities during Physical Education. As with any physical activity, there is a risk of injury. I fully accept this risk and hold harmless from any legal liability, Colonial Baptist Church (Virginia Beach, VA) and any persons involved in the Creation Explorers Co-op.
2) In the event of an emergency that requires medical treatment for the above named child/children, I understand every effort will be made to contact me or my emergency contact. However, if I/we cannot be reached, I give my permission to the Creation Explorers Co-op to secure the services of a licensed physician to provide the care necessary for my child's well being. I assume responsibility for all costs connected to any accident or treatment of my child.
I have read and agree to the Terms and Conditions stated above.
Printed Name: _____________________________________________
X____________________________________ /___________________
Signature of Parent/Guardian Date
rev. 8/2011
................
................
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