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Rcc - medical release

RCC Medical Release/Liability Waiver/Insurance Form
August 1, 2010 through August 31, 2011 NAME: __________________________________________________________________________
DATE OF BIRTH: _______________________________ PHONE: _____________________________
ADDRESS: _____________________________________________________________________

_____________________________________________________________________
I give my permission for my child (named above) to go with Rockingham Christian Church, Salem, NH, on congregation sponsored activities. I release Rockingham Christian Church, and its staff and volunteer leaders, from responsibility and liability for any injury or illness that my child/children may sustain during these activities. IN CASE OF EMERGENCY, I hereby authorize an adult leader of this activity, as an agent for me, to consent to any X-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a
physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state or country where the
services are rendered, either at a doctors office or in any hospital. I expect to be contacted as soon as possible and
before hospitalization or surgery is administered (unless the injury or il ness is life threatening).

Signature of parent/legal guardian: ______________________________________________________________

to food: ____________________________________ to medications: _________________________
to insect bites/stings: _________________________ to others (list): _________________________
Medications taken currently: __________________________________________________________________________
Date of last Tetanus Booster: ________________________________ (must have been within the last 10 years)
Please cross out any medication you do not allow your child to have:
Pain Relievers (Tylenol/Acetaminophen, Ibuprofen, aspirin, other _____________________________) Allergy Medication (Benadryl, other antihistamines, other ___________________________________) Cough Suppressants (__________________________________________) Decongestants (Sudafed, other ________________________________) Anti-diarrhea Medications (Pepto Bismol, Immodium, other ___________________________________) Other over the counter medications _____________________________________________________ Physical limitations/Current health conditions: __________________________________________________ Physician's Name: ______________________________________________________ Address: _________________________________________________________________________ Telephone Number: ___________________________________________ PLEASE ATTACH PHOTOCOPY OF INSURANCE CARD
Insurance Company: ________________________________________________________________________ Name of Insured: _________________________________________________________________ Policy #: ________________________ Group #: ______________________ Phone #: ________________________ Emergency Contact Information Print name of parent/legal guardian: ____________________________________________________________ Phone #s of parent/legal guardian: Home _____________________ Work _________________ Cel ________________ Names of other emergency contact person(s) and phone number(s): 1st _________________________________________________ Phone Number(s): _____________________________ 2nd _________________________________________________ Phone Number(s): _____________________________ 3rd _________________________________________________ Phone Number(s): _____________________________

Source: http://xtremegrace.net/~students/wp-content/uploads/2010/09/rcc-medical-release-pdf.pdf

Microsoft powerpoint - boehmer-sexualisierte-gewalt.ppt

Martina Böhmer Altenpflegerin für Geriatrische RehabilitationReferentin und Beraterin in der AltenarbeitGründerin , Mitarbeiterin bei Paula e.V., Martina Böhmer, Erfahrungen sexualisierter Gewalt in der Lebensgeschichte alter Frauen©, 2012, www.martinaboehmer.de, Zahlen zu sexualisierter Gewalt • Laut Kriminalstatistik werden in Deutschland jedes Jahr rund 20.000 Fäl e von sexue

Newsletter copy for january, 1999

Winter 2012 MANZANITA REPORTER CITY COUNCIL ADOPTS GOALS bicycle/pedestrian access between Nehalem Bay State Park and the downtown area, including In November, the Manzanita City Council adopted bicycle parking facilities in the downtown area. four major goals for 2012. Although these goals are similar to the ones developed by the Council CITY COUNCIL LOOKING FOR last year, t

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