Waiver And Medical Release Form
Download a blank fillable Waiver And Medical Release Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Waiver And Medical Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Appendix # 1
WAIVER AND MEDICAL RELEASE FORM (E-mail)
Steinmann Mennonite Church
Name of Child/Youth: ____________________________________________________
Age: ________________
Date of Birth ______________________
Address: ______________________________________________________________
Phone: _____________________
School: __________________________________
Emergency Contact and Phone Number if you are not available:
______________________________________________________________________
Does you child/youth have any severe allergies? (bee stings, food, penicillin, other
drugs) YES_____ NO ____
If yes, please explain: ____________________________________________________
______________________________________________________________________
______________________________________________________________________
Does your child/youth carry an Epipen?
YES _____ NO _____
Would your child/youth bring medication with him/her on an overnight event? (eg.
inhaler, Ritalin, insulin)
YES ____ NO _____
If Yes, please explain: ____________________________________________________
______________________________________________________________________
______________________________________________________________________
Check if your child/youth currently, or within the last three months, has had any of the
following:
Appendectomy ____ Asthma _____ Epilepsy ____ Hepatitis A or B _____
Bedwetting _____
Diabetes ____ Chicken Pox _____ Fainting _____ Other _____
Date of last Tetanus shot: _______________________
Does your child/youth have any concerns (physical or behavioural) that would limit their
full participation in our programs?
YES ____ NO ____
If yes, please explain: ____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Turn over
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal