Medical Release Form Page 2
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2The Health History is correct so far as I know, and the person herein described has permission
to engage in all prescribed activities except as noted.
Emergency Authorization- I hereby give permission to medical personnel selected by the
participant’s Church sponsor/his designee or camp staff to order X-rays, routine tests, and
treatment for my child. In the event of an emergency and neither the secondary contact nor
myself can be reached, I hereby give permission to the physician selected by the participant’s
Church sponsor/his designee or camp staff to hospitalize, secure proper treatment, order
injections and/or anesthesia and/or surgery for my child as named above. I further authorize
the release of the above medical information to appropriate medical personnel and/or the
health coverage insurance company. In addition, I have, and do herby, release the below
named event, its directors, employees, or agents from liability associated with participation in
the below named event.
____________________________________________________________________
Name of Event
____________________________________________________________________
Signature of Parent/Guardian Date
The following to be completed by the notary witnessing parent/guardian’s signature.
The state of _________________________ the county of _______________________
Before me, a Notary Public, on this day personally appeared ____________________
known to me (or proved to me on the oath of__________________________________)
to be the person whose name is subscribed to the foregoing instrument and acknowledged to
me that he executed the same for the purpose and consideration therein expressed. Given
under my hand and the seal of the office this
_______________day of ____________________, A.D.________________________.
______________________________________________
Notary Public, State of ___________________________
______________________________________________
Print name of Notary Public here
My commission expires the _________ day of______________, A.D.______________.
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