Medical Release Form for Special Events / Overnight Events (YOUTH) 

I, the undersigned, give permission for _________________________________________ to participate in ____________________________________ on _______________ , a special event sponsored by the Wetaskiwin Mission Church Youth Group. 

I, the undersigned, will not hold the Wetaskiwin Mission Church responsible for any medical or personal injury or any other loss or damage and, therefore, waive any claim against Wetaskiwin Mission Church. I, the undersigned, acknowledge that it is my responsibility to take the necessary steps for insuring against personal injury, loss, property damage, or any other loss or damage that might be incurred by my child, or to my child. 

In the event of injury or illness, I, the undersigned, authorize the Wetaskiwin Mission Church Youth Leaders, to seek and obtain surgical or medical attention for my child, in the event of an emergency, without the necessity of my prior approval. It is understood that if any emergency occurs, a responsible adult will ensure that my child receives proper medical attention and that arrangements will be made for my child’s return home (at no expense to the Wetaskiwin Mission Church), if necessary. I understand that I, the undersigned, will be notified by the quickest means if an emergency occurs. 

Parent / Legal Guardian: ______________________________________________ (please print) Parent / Legal Guardian: ______________________________________________ (signature) (The signature is required of the Parent / Legal Guardian of this participant, so as to concur with the terms listed above, if participant is under 18 years of age.) 

Phone #s of Contact: __________________ (home) ______________________(work) 

If I cannot be reached, please contact: _______________________ at _______________ (ph#) 

AB Health Care # ________________ Family Doctor & Ph #: _________________________ 

List of medications your child uses or medical conditions or allergies we should know about: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 

Wetaskiwin Mission Church 

R.R.#3, 3610 – 56 Avenue 

Wetaskiwin, Alberta T9A – 1X1 

Phone: 780-352-2512 

Fax: 780-352-2513 

Email: wmc@incentre.net 

Website: www.wetaskiwinmissionchurch.org