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Medical Release Form:
*
Indicates required field
Date
*
Student's Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Parent/Guardian Name
*
First
Last
Daytime Phone
*
Address (if different from above)
*
Line 1
Line 2
City
State
Zip Code
Country
Employer
*
Evening Phone
*
Are you currently taking medicine or treatment?
*
No
Yes
If yes, please explain:
*
Have you ever had a severe reaction to a bee/hornet sting or insect bite?
*
No
Yes
Not Sure
If yes, please explain:
*
Month & Year of last Tetanus Toxoid Immunization:
*
Do you have:
*
Sinus Trouble
Diabetes
Heart Trouble
Hay Fever
Asthma
Epilepsy
List Allergies:
*
Medications:
*
Other Medical Needs:
*
Emergency Medical Authorization:
In the event of an emergency, I hereby give permission to the church-appointed sponsors who are with my child at the event to obtain medical assistance for my child. I also give permission to the physician selected to hospitalize and secure proper treatment for my child.
Today's Date:
*
Parent/Guardian Name:
*
Insurance Company:
*
If I cannot be reached, please notify:
*
Activity Waiver/Release:
Participant's Name:
*
Address:
*
City, State, Zip Code
*
Date of Birth (MM/DD/YYYY)
*
Height & Weight:
*
If under 18, name of Parent/Guardian:
*
Address (if different from above):
*
City, State, Zip Code:
*
Phone Number
*
Policy Number:
*
Phone Number
*
Typed name is same as the Participant's signature:
*
Typed name is same as Parent/Guardian's signature if Participant is under 18:
*
Submit
Home
Worship
Calendar
About
Mission, Vision, Core Values
Staff & Deacons
Connect
AWANA Clubs
AWANA Registration
Children
>
Kids Night Out
Food Fight
VBS
Youth
>
Sunday Bible Study
Summer Camp
Bible Studies
Women
Men
Missions & Outreach
Music
Prayer
Upcoming Events
FAQ
Contact Us
Weekly Sermons
