I give permission for my above-named child to participate in the activity of American Christian Academy Identified above.  I hereby release American Christian Academy, its staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain while traveling to or participating in this activity.  In the event of an emergency, I 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 where the services are rendered, either at a doctor’s office or in any hospital.  I expect to be contacted as soon as possible.

Signature of Natural Parent/Legal Guardian: __________________________________

Date: Emergency Phone #:

Medical Information

Allergies:

Medications Being Taken:

Physical Handicaps or Limitations:

Medical Insurance Company:

Policy #: Member’s Name: