River Valley Church - Student Form

Student DNOW Medical and Liability Form

Student's Name

Student's Age

Student's Birthdate

Student's Grade

Name of Parents

Address 1

Address 2

Country

City

State

Zip/Postal Code

Parent Cell Phone Number

Parent Email

Medical Treatment and Liability Release - I/We the undersigned, parent or legal guardian for the above-name student, do hereby give permission to River Valley Church (“RVC”) and its representatives to obtain any necessary medical treatment for my student during the conduct of DNOW at RVC. For and in consideration of RVC allowing my student to participate in DNOW, the undersigned, for himself/herself, assigns, heirs, and next of kin (“Releasors”), release, waive, discharge, and covenant not to sue RVC or their employees, officers, members, elders, or agents (“Releasees”), on account of injury or death to my student or injury to the property of my student, whether caused by negligence of the Releasees or otherwise, while my student is participating in DNOW. As the parent/legal guardian, I/we are responsible for becoming fully aware of the risks and other hazards inherent in DNOW in which my/our student will participate. Understanding this obligation, I/we permit my/our student to participate in DNOW, and I/we voluntarily assume all risk involved in Summer Camp and all other risks of loss, damage, or injury that may be sustained by my student while participating in DNOW. If any injury occurs the family/individual’s insurance will serve as primary coverage.

Insurance Company Name

Policy Number

Mother's Name

Date of Birth

Father's Name

Date of Birth

Parent or Guardian's Signature

Date

Medical Administration Plan: Please list all medication taken by the student along with instructions for administering the medication. Please include time of day and amount for each medication. ALL medication prescription or non-prescription must be turned in, by the parent or guardian, to Pastor Gavin before the event and will be administered by Pastor Gavin and returned to the parent or guardian upon the conclusion of the event. (See medication turn-in policy)

Please list all allergies that the student suffers from and what should be done in case of an allergic reaction.

Please list any special dietary restrictions that the student has.

Please check any of the following medications that you would NOT want the student to receive if needed:
Tylenol
Advil
Benadryl
Tums

Student's Name

Parent or Guardian Signature

Cell Phone Number

Home Phone Number

Work Phone Number

Submit

Student DNOW Medical and Liability Form

Medication Turn-In Policy

Please sort your medicine this way:
- Individual bags for each time your child will take medicine. (For example: If your child takes a pill every morning, please include a bag for Saturday morning and Sunday morning)
- We suggest snack size bags or little pill bags, please no gallon size bags. Please write in permanent marker so that it does not smudge off. We will have little pill bags you can pick up at MIDWEEK, or you can use your own bags from home. Please sort your medication before you arrive so that check-in goes smoothly
- On the bag, please put your child's first and last name, the day it will be taken and if it is taken in the Morning, Evening or Bed. (Morning will be handed out at breakfast, Evening with dinner and bedtime will be given out as soon as we start getting ready for bed so if it’s a sleep aid it will have time to kick in). We are trying to keep medicine distribution to these times. If they need to be taken at a different time than this, please let us know at check in.

Example: If your child takes morning medicine, dinner medicine and bedtime medicine you will be bringing 5 bags. It will look something like this...(images may not show on phones)

- As-needed medication
- Please put bottle/ EpiPen/ Inhaler in a bag
- Put the child's first and last name on the bag
- Instructions in/on the bag
When you check-in, one of our volunteers will help you put each baggy into the correct ‘day’ and ‘time’ bag. Then throughout the weekend, we will distribute the baggy to the student, and they will be responsible to take the medication.