Child Medical Release Form printable pdf download

Child Medical Release Form

To be used for any children’s ministry activities or childcare when a parent/guardian is not present

PLEASE PRINT LEGIBLY

Parent/Guardian Information

Parent/Guardian Name(s):_______________________________________________________________________

Phone Numbers: (H):__________________________________________________________________________

(Cell):_________________________ Who should we ask to speak to? __________________________________

Home Address: _______________________________________________________________________________

City: __________________________________ State: ________________ Zip:_____________________________

Email Address: ________________________________________________________________________________

Emergency Information

In case I cannot be reached, either of the following is designated. In addition, I authorize Christ Church to

release my child(ren) to these persons in the event I am unable to pick up my child(ren).

Name: _________________________________________________ Phone: _______________________________

Child Information

Please complete for each child.

Child’s Name: _________________________________________ Birth Date:______________________________

My child’s physician: ___________________________________________________________________________

Physician’s Phone:_____________________________ Address:________________________________________

My insurance policy number is: __________________________________________________________________

The phone number for the insurance company is: ___________________________________________________

List any medications to which child is allergic:_______________________________________________________

Known allergies or medical conditions of child:______________________________________________________

____________________________________________________________________________________________

Medications child takes: ________________________________________________________________________

Any other helpful information: ____________________________________________