Medical Release Form printable pdf download

Alma First Church of God

MEDICAL RELEASE FORM

September 2016 through August 2017

STUDENT INFORMATION:

Student’s full name _____________________________________________________________

Address __________________________________City_______________________State______

Phone_________________________________________

Birth date______________________________

EMERGENCY CONTACT INFORMATION:

In case of emergency, contact:

Name __________________________________Day phone______________________________

(parent/legal guardian)

Evening phone_____________________________

MEDICAL INSURANCE INFORMATION:

Insurance Co. __________________________________________________________________

Ins. Co. Address & Phone ________________________________________________________

Policy No. ______________________________Other Information________________________

LIST ALL ALLERGIES YOUR CHILD HAS AS WELL AS ANY OTHER

INFORMATION THAT A DOCTOR MIGHT NEED TO TREAT YOUR CHILD:

______________________________________________________________________________

Please indicate any SPECIAL DIETARY NEEDS/RESTRICTIONS:

_____________________________________________________________________________

Name and number of your family doctor:__________________________________________

This consent form gives permission to seek whatever medical attention is deemed necessary, and

releases the Church and its staff of any liability against personal losses of named child.

In the event of a situation (emergency or non-emergency) in which medical treatment is required while the

above named person is participating with the Alma First Church of God, every effort will be made to

contact the person or persons listed above. If attempts to contact these persons are unsuccessful,

consent/permission is hereby given for treatment by those adults who have access to this form, or to

other competent medical personnel.

(please SIGN THE BACK of this form)

Medical Release Form