Frazer United Methodist Church Child/student Permission & Release Form
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2Frazer United Methodist Church Child/Student Permission & Release Form
For your child’s protection, we ask every parent/guardian to submit a form each year on each child. This form covers over-
night trips as well as church programs, so not all questions may apply to your situation, but please fill it out as completely as
possible to ensure we can provide the best care for your child/student in case of emergency. Children/students will not be
allowed to attend any overnight or off-campus event without a completed and notarized form on file for the current year.
CONTACT INFORMATION
Last Name:
First:
Middle:
Birthdate:
Age:
o Male o Female
School:
Street Address:
City:
State:
ZIP:
Father/Guardian Name:
Home Phone:
Cell/Work/Other Phone:
Address (if different):
Email:
Mother/Guardian Name:
Home Phone:
Cell/Work/Other Phone:
Address (if different):
Email:
Emergency Contact (if parent can’t be reached):
Phone:
Family Physician/Name of Practice:
Phone:
HEALTH HISTORY
(Check all that apply; attach additional sheet if necessary)
o Frequent ear infections
o Bleeding/clotting
o Whooping Cough
Allergies
Subject to...
o Frequent cold/sore
disorder
o Hay Fever, etc.
o Tuberculosis
o Sleep Walking
throat
o Hypertension
o Poison Ivy/Oak/Sumac
o Polio
o Fainting
o Sinusitus/Bronchitus
o Stomach Problems
o Insect Stings
o Diabetes
o Strep Throat
o Chicken Pox
o Penicillin
o Bedwetting
o Asthma
o Mononucleosis
o Measles
o Aspirin
o Arthritis
o Constipation
o Heart Defect/Disease
o Mumps
o Food/Other Allergies
o Epilepsy/Convulsions
o German Measles
(describe below)
o Other (describe below)
Other diseases or details of diseases, conditions or allergies above:
Recent exposure to contagious illness:
Operations, Serious Injuries (describe and give dates):
Immunizations up to date? o Yes o No–explain:
Date of last tetanus shot:
Date of last TB skin test:
Swimming, diving, or activity limitations?
Other activities to be encouraged or restricted?
Special medical or dietary regime to be continued?
List any medications or drugs taken regularly (current or recent):
Can your child take Tylenol? o Yes o No
Does your child wear contact lenses? o Yes o No
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