C3 Medical Release Form Page 2
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Complete C3 Medical Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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2Insurance Information
This information will be requested by the physician and medical facility in the event of an emergency. Please
help us by making sure you give complete and correct information. This Medical/Release Form is valid for one
year to date of Parent/Guardian signature and is valid for all C3 – Conroe Community Church sponsored
activities. If any of the information you have provided should change before this date, please complete a new
form and return it to the church office.
Parent/Guardian_____________________________________________________________
Social Security Number of Insurance Policy Holder _________________________________
Policy carried under what name_________________________________________________
Parent/Guardian Occupation___________________________________________________
Employer Name_____________________________________________________________
Employer Address___________________________________________________________
City
State
Zip
Insurance Company Name_____________________________________________________
Insurance Company Address___________________________________________________
City
State
Zip
Insurance Company Phone____________________________________________________
Member/Policy Number_________________________Group Number__________________
Please explain any medical problems____________________________________________
__________________________________________________________________________
Please list any medication being taken and what is being taken for:
__________________________________________________________________________
__________________________________________________________________________
Please list any medication that would cause an allergic reaction:
__________________________________________________________________________
Date of tetanus shot__________________________________________________________
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Parent category: Legal