The undersigned does hereby give permission for myself, _______________________ _____________________________, to attend and participate in The Biggest Loser Contest sponsored by St. Timothy's Episcopal Church, including but not limited to, group exercises, diet plans, work out regimens, and weekly weigh ins. I am familiar with the hazards of vigorous activity and further understand the potential hazards of diet plans and injuries resulting in exercise routines. I, also, recognize the medical complications resulting from possible workout schedules in which I may engage. I hereby unconditionally release and absolve St. Timothy's Episcopal Church and all clergy, staff, and volunteer leaders involved in these activities from liability for any accident. In case of emergency, I understand that every effort will be made to secure proper treatment. I hereby give permission for such treatment and consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician, dentist or licensed hospital whether such diagnosis or treatment is rendered at the office of said physician/dentist or at said hospital. My personal health and accident insurance covers any accident or illness that may be incurred during this experience. I will personally guarantee any cost of other liability incurred during evacuation or treatment. I consent to the use of any visual or audio reproduction that may be taken of the above named participant during TBL sponsored activities to be used, distributed, or shown as St. Timothy’s Episcopal Church sees fit, including being posted on St. Timothy’s Website (for advertising parish life activities). ____________________________________

In case of any illness or injury, contact:

_____________________________________________________________________ Address (PLEASE SIGN REVERSE SIDE)
HEALTH INVENTORY, September 2009– Aug. 2010
Address ____________________________________ City ________________________ State ______ Cell Phone __________________________
Email _______________________________________________________________________
Emergency Contact Information:
1. Name __________________________________ Contact Phone _________________
2. Name __________________________________ Contact Phone _________________
Insurance Company ___________________________________________________
Insurance Policy Number ____________________________________________
Date of last physical exam _________ Date of last tetanus booster_________
Doctor's Name ______________________ Telephone __________________________
Dentist's Name ______________________ Telephone __________________________
Hospital Preference: Baptist _________ Forsyth ________ Other ______________________
___NO ___YES Specify __________________________ HAVE YOU HAD:
Serious Illness?
___NO ___YES Specify __________________________ ___NO ___YES Specify __________________________
Take daily medication? ___NO ___YES Specify ______________________
Take emergency medication? ___NO ___YES Specify _______________________________
Have permission to take, if needed: Tylenol/Ibuprofen

Do you have any special dietary concerns or needs? _________________________________




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