Medical Release Form
This form must be signed and notarized.
Name of Church:_______________________ City/State:________________________
Name:______________________________ Social Security #:____________________
Birthdate:____/____/______ Age:____ Sex (M/F):_____
Address:_______________________________________________________________
City:_________________________ State:____________________ Zip:_____________
Parent/Guardian:________________________________________________________
Home Phone:(___)________________Work Phone:(___)________________________
Secondary contact to notify in event of emergency:_____________________________
Their relationship to you:__________________ Their phone:(___)_________________
Please supply ALL of the following information. Attach a copy of your insurance card.
Medical Insurance Co.:___________________ Group#________ Policy#:___________
Company’s address:____________________ Company’s Phone:(___)_____________
City:________________________ State:____________________ Zip:_____________
Family Physician’s Name:_______________________ Phone:(___)________________
Physical Limitations (Asthma, diabetes, allergies, etc.), and/or special instructions
(Allergic to certain meds, rare blood type, wears contact lenses, etc.):
______________________________________________________________________
______________________________________________________________________
List ALL medication taken on a regular basis and/or any brought with (Prescription meds
MUST have pharmacy label and doctor’s name:
______________________________________________________________________
______________________________________________________________________
List all operations/serious injuries and dates within the past five (5) years:
______________________________________________________________________
______________________________________________________________________
Date of last Tetanus Shot:_________________________________________________