Medical Release Form

Child-Participant's Name:
Parent's Name:
Address:
City:		State: Zip:
Home Phone:
Work Phone (Father):		Work Phone (Mother):
Cell Phone (Father):		Cell Phone (Mother):

Person to contact if parents are unavailable:
Relationship to Child:		Contact's Phone:
Physician's Name:		Physician's Phone:
Hospital Preference:
Allergies:
Medical problems we need to know about:
Doctor prescribed medications your child may be taking:

Saline County Christian Home Education Association (SCCHEA) is a non-profit organization. By Participating in SCCHEA athletic activities, you as parent or guardian are assuming all legal and moral responsibility for your child (children). By signing this form, you are attesting that you accept all financial responsibilities concerning any medical emergencies and you fully agree to provide medical coverage for any injury sustained by your child while participating in ANY SCCHEA activity. Therefore, in consideration for being accepted by Saline County Christian Home Education Association (SCCHEA) for participation in athletic events, as parent or guardian of child participant, we (I) do hereby release, forever discharge, and agree to hold harmless SCCHEA, its officers and volunteers, league affiliates, Arkansas Christian Conference, Highland Heights Baptist Church, Holland Chapel Baptist Church, First Southern Baptist Church, and Zion Lutheran Church from any and all liability, claims, or demands for personal injury, sickness or death incured while participating in SCCHEA athletic activities. On behalf of our (my) child participant, we (I) hereby assume all risk of personal injury, sickness, or death, as a result of participation in SCCHEA athletic activities. Authorization and permission is hereby granted SCCHEA to seek any necessary medical, dental, or otherwise emergency services for said child participant.

Insurance Company Name:		Phone:
Group/Policy Number:		Employee Name:
Employee SSN (optional)

Father's Name or Legal Guardian:	Signature:	Date:
	____________________
Mother's Name or Legal Guardian:	Signature:	Date:
	____________________