Medical/permission And Release Form

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Medical/Permission and Release Form
This Form Is Valid For All Church-Sponsored Youth Activities
Church
Address:
Name:
Age:
SS#:
DOB:
Phone:
Address:
State:
Zip:
In Case of an Emergency Notify:
Relationship:
Phone:
Family Physician:
Phone:
Family Insurance Company:
Policy #:
Immunizations:  Tetanus  Polio Booster  Measles  Mumps  Other
Past Medical History: (Check giving appropriate information)
 Asthma  Sinusitis  Bronchitis  Kidney Trouble  Heart Trouble  Diabetes
 Dizziness  Hay Fever  Stomach Upset  Other
Allergies: Food(s):
Penicillin or Other Drug(s) (Name):
Insect Stings/Bites:
Poison Sumac, Ivy, or Oak:
Previous Operations or Serious Illness:
Any Current Medication(s) List:
Special Diet (Name):
Childhood Diseases:  Chickenpox  Measles  Mumps  Whooping Cough
 Other
Permission for Treatment:
My permission is granted for the
Church, Pastor, Minister
of Music, Youth, and other staff personnel or other adult(s) in charge to obtain
necessary medical attention in case of sickness or injury to my child.
I, the undersigned, do hereby verify that the above information is correct and I do
hereby release and forever discharge all sponsors and the
Church from any and all claims, demands, actions or causes of action, past, present, or
future arising out of any damage or injury while participating in a church-sponsored
youth activity.
Dated this
day of
, 20
in the state of
County of
___
.
Signature:
Relationship:
On this the
day of
, 20
personally known by me and in my presence,
executed the within and foregoing Medical/Permission and Release form. Witness my hand and
official seal.
My Commission Expires:
Notary Public
 
 

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