Fillable Parental Consent, Medical, And Liability Release Form printable pdf download

Inside Out Student Ministries / Chapel of the Hills Church

Parental Consent, Medical, and Liability Release Form

Student’s Name: ______________________________________________________________________________

LAST FIRST INITIAL

Age ________ Birthday ________________ Male Female School Name:________________________________________ Grade ______

Home Address ________________________________________________ City ___________________________ State _______ Zip______________

Home Phone ________________________ Student cell ___________________________ Student Email: ___________________________________

Student lives with: Both Parents

Mother

Father

Other Guardian

Mother’s (guardian) name ___________________________________ Phone: Home _______________________ Work _______________________

Mother’s email __________________________________________________ Cellphone _________________________________________

Father’s (guardian) name ____________________________________ Phone: Home _______________________ Work _______________________

Father’s email ___________________________________________________ Cellphone _________________________________________

Emergency Contact (other than parents) ______________________________________________ Relationship ______________________________

Emergency Contact Phone: Home ____________________________ Work ________________________ Cellphone __________________________

Medical Insurance Carrier ______________________________Phone: ___________________________Policy # _____________________________

Physician _____________________________________________ Office phone ________________________________

Dentist _______________________________________________ Office phone ________________________________

MEDICAL HISTORY

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or

condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this

notification in writing and attach it to this form. Include names of medications and dosages that must be taken.

Check the following areas of concern for this student. If necessary, add another page with details:

1. Does your child have any allergies (i.e. pollens, medications, food, insect bites)? Yes No

If Yes, please describe allergy and treatment: ________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:

asthma epilepsy / seizure disorder heart trouble diabetes

frequently upset stomach physical handicap

3. Date of last tetanus shot: _______________________________________

4. Does your child wear

glasses contact lenses none

5. Does your child take regular and/or daily medication? Yes No

If Yes, please list medications taken and frequency: ___________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

6. Please list and explain any major illnesses the child experienced during the last year: ________________________________________________________________

Additional comments:

Should this child’s activities be restricted for any reason? Yes No Please explain (attach additional page if necessary):

_______________________________________________________________________________________________________________________________________