NearHim Home Educators

Membership Online Medical Release Form

indicates a required answer

1. *	Parent first and Last name

2. *	Home Address

3. *	Parent Cell Phone

4. *

Emergency Contact

Name First and Last

Relationship to child

Cell Phone Number

5. *	Pediatrician Name and Telephone Number

6. *	Dentist Name and Telephone Number

7. *	Insurance Company Name- mark N/A if none

8. *	Insurance Policy#/Group #- mark N/A if none

9. *	Insurance Telephone Number- mark N/A if none

10. *

1. Child's First and Last Name - Only list children taking part in any activity with NHE.

Birthdate

Allergies or other important medical information

11. *

2. Child's First and Last Name- mark N/A if no more children to list

Birthdate

Allergies or other important medical information

12. *

3. Child's First and Last Name- mark N/A if no more children to list

Birthdate

Allergies or other important medical information

13. *

4. Child's First and Last Name- mark N/A if no more children to list

Birthdate

Allergies or other important medical information

14. *

5. Child's First and Last Name- mark N/A if no more children to list

Birthdate

Allergies or other important medical information

15. *	List additional children together in this area- and God BLESS you if you have children to fill this space:-)

Medical Release and Liability Release

The undersigned hereby authorizes any adult working with NearHim Home Educators, or any individual officially appointed by someone of the above group or such substitute as any one of the above may designate to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment deemed advisable for and to be rendered under the general or special supervision of any licensed physician and/or surgeon or licensed dentist, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere for the minor(s) listed above.

Release of liability in favor of NearHim Home Educators (NHE), NearHim Home Educators Discovery Co-op, NearHim Home Educators Excel Co-op, Northland, A Church Distributed, Gateway Church, and Seminole Community Church (SCC) or any other location:

Further, the undersigned agree that NHE, NHE Discovery, NHE Excel, NACD, or any individual operating on behalf of or in conjunction with NHE, NHE Discovery, NHE Excel, NACD, CEC, GC, and SCC, or any subdivision thereof shall be held harmless from any liability for damages to person or property to the adults or minor(s) named herein arising from or as a consequence of any involvement or participation by said adult or minor in a program or activity of NHE, NHE Discovery, NHE Excel, NACD, GC, and SCC ot any other location.

16. *	By typing in my name I agree that this is a binding electronic signature agreeing to the above as true.