Adult Medical Assistance Form

Adult Participant's Information
Full Name*
First NameLast Name
Church/Group*
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Phone Number*
Area CodePhone Number
E-mail*
Birth Date*
MonthDayYear
Gender*
Grade*
Insurance Co.*
Policy #
Group #
Family Doctor Name*
Allergy and Medical Information*
Medications (over-the-counter and prescription)*
Medical Liability Release:
I, the undersigned, do hereby consent to the participation in all of The Philadelphia Project & Roxborough Church ministry events for the year of January 2017 through December 2017. This includes activities both on and offsite, including but not limited to mission trips and retreats. Further, I certify that I am physically fit to participate in these activities. . However, in the event that I am injured or become ill I authorize the calling of a doctor and the providing necessary medical services. I understand neither The Philadelphia Project, Roxborough Church, nor the ministry staff may be held responsible for medical expenses incurred, but that such expenses will be my responsibility.
Photo Release:
I, also grant permission to The Philadelphia Project & Roxborough Church to Publish pictures & videos of myself on The Philadelphia Project website, in promotional videos, press releases, or any other form of public publicity.
Statement of Rules and Expectations:
I also understand that all participants are expected to adhere to the following rules:
1. No use or possession of tobacco products, alcohol, or illegal drugs.
2. No use of inappropriate language will be permitted.
3. Cell phone use will be limited.
4. No leaving activity locations without permission from a leader.
5. Inappropriate displays of affection will not be permitted.
6. No disrespect to the adult leaders or other students will be tolerated.
I have completed the above, and have read these ruled and understand that if there are any disciplne problems with my child, that I am responsible for picking up my child from any activity of The Philadelphia Project at any time and location necessary.
Participant's Signature*
Clear
Should be Empty:

Adult Participant's Information

Medical Liability Release:

Photo Release: