Medical Consent & Media Authorization Form printable pdf download

Hesperia Community Church

Medical Consent & Media Authorization Form

(760) 244-2805

Please Print

Name_________________________________________________ Sex: M F Birthdate ____/____/____ Age______

Last

First

circle one

Address______________________________________________________ Phone (______) ___________ Grade___

City ________________________________________ State ______ Zip______________ Grade in the Fall of 20__ __

EMERGENCY INFORMATION:

Father’s Name or Legal Guardian

Mother’s Name or Legal Guardian:

__________________________________________

Home Phone (____)__________________________

Home Phone (____) _________________________

Work Phone (____) __________________________

Cell Phone (____) ___________________________

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 #______________________

MAJOR MEDICAL PROBLEMS

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

Church.

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________________

Medical Consent & Media Authorization Form

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