Student Ministries Participation Agreement And Medical Release

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May 2015 - April 2016
Student Ministries Participation Agreement and Medical Release
STUDENT INFORMATION:
Name
Grade
(School Year 2015/2016)
Address
Date of Birth
/
/
City
State
Zip
Home Phone (
)
-
Medical Insurance Company
Policy Number
Allergies to Medicine or other
Current Medications:
**if student is taking any medication, additional paperwork will be emailed to you prior to event/camp**
Date of last tetanus immunization (mm/yy)
PARENT/GUARDIAN INFORMATION:
Primary Adult in House:
Secondary Adult in House:
Cell Number:
Cell Number:
(
)
-
(
)
-
Relationship to student (circle one):
Relationship to student (circle one):
Dad
Mom
Step-Dad
Step-Mom
Other_______
Dad
Mom
Step-Dad
Step-Mom
Other_______
Mailing address: ( if different from student)
Main Contact Email:
Emergency Contact:
Relationship to Student:
(other than names above)
Emergency Phone:
(
)
-
MEDICAL RELEASE: By signing below, as the parent or legal guardian, having legal custody of the above named youth, I give
permission for a licensed doctor, physician, or emergency treatment center, selected by the person in charge of any Red Mountain
Community Church event, to administer the necessary attention and aid immediately to our child should he/she become injured or sick
at any event during the dates of May 2015- April 2016 and to do so without having to wait until I have been contacted. I furthermore
understand that I will be held liable for the expense of that treatment. I consent to X-rays, examination, anesthetic, medical or surgical
diagnosis, treatment, and hospital care. I understand the event leader will endeavor to reach us should the nature of the injury or illness
warrant it. However, we will not hold any of the event personnel responsible if efforts to contact me are unsuccessful.
(Continued on reverse side)

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