Medical Release Liability Release Permission Slip Form
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3Medical Release/Liability Release Permission Slip Form
Please Fill Out Completely
Child’s Name:_____________________________________ Home Phone (_____) -_____-_________
Birthday (M/D/Y) ___________________________ Sex (M) ______ (F) ______ Age:_____________
Street Address:______________________________________________________________________
City:______________________________________________ State: _________ Zip:______________
All First Assembly of God of Fort Myers, Florida, Inc. Events
From January 1, 2014 through December 31, 2014
MEDICAL RELEASE
In the event my child (children) becomes ill or is injured while under church supervision, I authorize the “Person In
Charge” (defined as the person in charge of First Assembly of God of Fort Myers, Florida, Inc.’s participation in any
church event or the Person In Charge’s designee) to take the following steps in the following order:
1.
Contact the parents of the child and follow his/her instructions.
2.
In the event of an emergency when neither parent can be contacted, the Person in Charge will immediately attempt to
contact the child’s physician and follow his/her instructions.
3.
If the child’s physician cannot be immediately reached, the Person In Charge will use their own discretion in
contacting a properly licensed practicing physician or the nearest hospital and follow his/her instructions.
4.
At the same time as the preceding steps are occurring, I authorize the “Person In Charge” to call for/order emergency
medical services for the child.
If in the opinion of a properly licensed and practicing physician my child needs medical or surgical services which require
my consent before being supplied, and I cannot be reached, I hereby authorize, appoint and empower the “Person In
Charge” to furnish, on my behalf, such written or oral authorization as may be so required.
Further, I release First Assembly of God of Fort Myers, Florida, Inc. and its representatives from any liabilities which
might arise from the giving of such authorization, it being my desire that my child be furnished with such medical or
surgical services as soon as reasonably possible after the need arises.
ALLERGIES AND/OR SPECIAL MEDICAL INFORMATION
Statement of Health (To be filled out by parent or guardian)
Emergency Phone – Cell (_______) _______-______________
Work (_______) _______-_____________
Parent or guardian:_______________________________________ Employer: ___________________________________
Family Insurance Company: ______________________________________ Policy # ______________________________
Name of Insured: _______________________________________________ Phone # ______________________________
Primary Care Physician: __________________________________________Phone #______________________________
Health Problems/Limitations:___________________________________________________________________________
Immunizations: Date of last Tetanus Shot/Boosters: _________________________________________________________
List medication(s) participant is currently taking: ___________________________________________________________
List all medications that participant is bringing: ____________________________________________________________
ALLERGIES (check any that apply):
□ Drugs □ Plants □ Food □ Bee Stings □ Other _________________________________________________________
□ Yes □ No: My child can be given pain reducing medication (i.e., Tylenol, aspirin, etc.) as deemed necessary by Person
In Charge. If NO, please list medications not to be dispensed: _________________________________________________
**All medications, including non-prescription drugs must be turned into the “Person In Charge” upon arrival.
Medical Release
Page 1 of 2
Revised 12/16/2013
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