Medical Consent Waiver
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1
2Allergies? Yes____ No _____
Describe below
CONFIDENTIAL
MEDICAL CONSENT/WAIVER
The undersigned does hereby give permission for our (my) child, to attend and participate in activities sponsored by
FIRST ALLIANCE CHURCH, 2201 Old Higbee Mill Rd, Lexington, KY 40514.
Child’s Full Name (Please Print)
Sex
Birthday
______
Parent or Guardian Name (Please Print)
Street Address
City
State
Zip
Phone (
) -
Alternate Phone (
)
If not available in an emergency, notify:
1.
Name
Phone (
)
Street Address
City
State
Relationship to Child (friend, grandparent, etc.)
OR
2.
Name
Phone (
)
Street Address
City
State
Relationship to Child (friend, grandparent, etc.)
Does this child have any allergies? Please list
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Does this child have any medical or health problems and has this child had any chronic or recurring illness or
illnesses, which would have an effect on the child’s participation in any Activity?
( ) Yes
( ) No
If yes, describe the problems or illnesses
Indicate the date of this child’s last tetanus shot
Are there any activities such as strenuous activities, to be restricted for this child?
( ) Yes
( ) No
If yes, describe:
Is this child on any medications? ( ) Yes
( ) No If yes, please state medication:
If so, will this child be bringing medications that he/she will be taking to the activity… ( ) Yes
( ) No
Describe any dietary restrictions that this child is required to observe
State the name, address, and phone number of this child’s Pediatrician/Family Physician or any other physician who
should be consulted in the event of emergency or medical problems involving this child:
State the name, address, and phone number of this child’s dentist (and orthodontist if applicable):
Is there medical or hospitalization insurance which provides benefits for this child?
. If so, indicate:
Name of Insurance Company
Address
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