Girls Emergency Medical Release Form

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THIS FORM MUST BE NOTARIZED
Name of Church _______________________
Today’s Date _____________________
City ________________________
GIRLS
EMERGENCY MEDICAL RELEASE FORM
Each attendee must turn in this Emergency Medical Release form before she will be permitted to participate in
District Girls Ministries event activities. Please turn in upon arrival, and pick up before departure for home.
DO NOT SEND THIS FORM TO THE DISTRICT OFFICE
NAME __________________________________________ Phone (______) _________________
D.O.B. _____/_____/_____
ADDRESS _________________________________________________________________________________________________
My child is a swimmer / non-swimmer and
has / does not have my permission to swim (
).
(Circle one)
(Circle one)
(Date)
IF PARENT/GUARDIAN CANNOT BE CONTACTED, PLEASE NOTIFY:
Name ____________________________________________
Name ____________________________________________
Phone (H) ______________ (C) _____________________
Phone (H) ______________ (C) _____________________
Minor’s Physician ______________________________________ Phone _______________________________________________
Medical/Hospital Insurance Carrier ________________________________________
Policy/Group # ______________________
Are you a member of HMO? ____________________
Policy # _________________________________________________
Date of last examination _________________________________
Is activity restricted? _________ No _________ Yes
Explain: ____________________________________________________________________________________________________
IMMUNIZATIONS: Are school shot records current? (circle one)
YES
NO
CHRONIC/RECURRING CONDITIONS: (Please check any that apply)
_____ Seizure Disorders
_____ Diabetes
_____ Fainting
_____ Headaches
_____ Heart Disease
_____ Kidney Disease
_____ Nosebleeds
_____ Asthma / Respiratory problems
Other: _______________________________________________________________________________________________________________
ALLERGIES: (Check all that apply; be specific. If no allergies, circle NONE)
______ Animal _____________________________
________ Plants ______________________________________
______ Food _______________________________
________ Pollen ______________________________________
______ Insect Bites __________________________
________ Medicines / drugs ____________________________
______ Other ___________________________________________________________________________________________
May be given Tylenol?
_____ Yes _____ No
May be given cough drops?
_____ Yes _____ No
Has begun menstruation?
_____ Yes _____ No
Is informed about Menstruation? _____ Yes _____ No
Is in child’s possession?
Current medications: _______________________________
_____ Yes _____ No
Child wears:
_____ Contact Lenses
_____ Glasses
_____ Dental appliance
___________________ Other
Does your child ever sleepwalk?
_____ Yes _____ No
IN CASE OF EMERGENCY I CAN BE REACHED AT __________________________________________________________
(Area code and Phone number)
Parent/Guardian Statement: I authorize the adult in charge to consent to medical treatment if I cannot be contacted. I understand that every effort will be made to
contact me before such action is taken. I assume financial responsibility for emergency care if such care is not covered by church’s insurance.
____________________________________________________
____________________________________________________
PRINT MOTHER’S NAME
PRINT FATHER’S NAME
____________________________________________________
____________________________________________________
Mother’s Signature
Father’s Signature
____________________________________________________
____________________________________________________
Address / City / Zip
Address / City / Zip
(_____) _____________________________________________
(_____) _____________________________________________
Phone
Phone
Subscribed and sworn before me this ________________ day of ______________________________________ 20 __________________
_________________________________________________________________________
Notary

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