Medical Consent & Media Authorization Form


Hesperia Community Church
Medical Consent & Media Authorization Form
(760) 244-2805
Please Print
Name_________________________________________________ Sex: M F Birthdate ____/____/____ Age______
circle one
Address______________________________________________________ Phone (______) ___________ Grade___
City ________________________________________ State ______ Zip______________ Grade in the Fall of 20__ __
Father’s Name or Legal Guardian
Mother’s Name or Legal Guardian:
Home Phone (____)__________________________
Home Phone (____) _________________________
Work Phone (____) __________________________
Work Phone (____) __________________________
Cell Phone (____) ___________________________
Cell Phone (____) ___________________________
Pager (____) _______________________________
Pager (____) _______________________________
If Parents or Guardian are unavailable, call:
Alternate Contact/Relationship:____________________________________________ Phone:___________________
Health & Insurance Information
Do you carry family medical/hospital insurance? Yes_____ No_____
If so, indicate Insurance Carrier________________________________________ Policy #______________________
Name of Family Physician____________________________________________ Phone #______________________
Name of Family Dentist/Orthodontist____________________________________ Phone #______________________
Allergies: Asthma____ Drug Allergies____ Hay Fever____ Insect Stings____ Other Allergy______________________________
Asthma(chronic)____ Bleeding/Clotting Disorder____ Cardiac____ Diabetes____ Epilepsy____ Emotional Disorder____
Nervous Disorder____ Physical Handicap____ Seizure Disorder____ Other condition___________________________________
If you have checked any of the above, please give details:________________________________________________
Activity Restrictions?______________________________________________________________________________
List operations or serious injuries with dates:___________________________________________________________
List any chronic, recurring illness or medical condition:___________________________________________________
Current medication: (send with instructions)____________________________________________________________
Date of last tetanus shot: (mo/day/yr)___/___/___
IMPORTANT: Please notify Hesperia Community Church (HCC) if your child has been exposed to a
communicable disease within three weeks prior to an outing or event.
This health information is correct so far as I know, and the person described has my permission to engage in all
prescribed activities except as noted. Authorization for treatment: I hereby give permission to the medical personnel
selected by HCC to order X-rays, routine tests, treatments; to release any records necessary for insurance purposes;
and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an
emergency, I hereby give permission to the physician selected by HCC to secure and administer treatment, including
hospitalization, for the person named above. This form, when complete, may be photocopied for trips away from the
Media Authorization: I hereby also give HCC permission to use any audio, video and/or photography of my child for
HCC’s promotional purposes including but not limited to internet, printed media and videos.
Signature of Parent of Legal Guardian____________________________________________Date________________


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Parent category: Business