Medical Release Form printable pdf download

MEDICAL RELEASE FORM

The Church at Canyon Creek

9001 FM 620 North

Austin, TX 78726

Name__________________________________________________________ Birthdate_______________ Age____________

Home Address___________________________________City______________________State_______ Zip ______________

Home Phone Number_____________________Office Phone (Dad)_______________Office Phone (Mom)_______________

Parent or Guardian______________________________________________________________________________________

Doctor’s Name____________________________________________________Phone Number_________________________

Insurance Company________________________________________________Phone Number_________________________

Address__________________________________________________Policy or Group #______________________________

In the event of an emergency, give the name and phone number of friends or relatives we can contact who will know how to

reach parents or guardians:

Name_____________________________________Relationship________________________Phone____________________

List medications taken regularly____________________________________________________________________________

List known food/drug or other allergies and medical conditions___________________________________________________

__________________________________________________________Date of last Tetanus Shot_______________________

Swimming: My youth is a (check one)

Non-Swimmer __________ Fair Swimmer_________ Good Swimmer_________

Any other special instructions regarding youth

PARENT/GUARDIAN PERMISSION:

I hereby give my permission for ____________________________ to take part in various sponsored trips, outings, and camps

of The Church at Canyon Creek of Austin, TX. I also give my permission for my child to be transported in vehicles used in

conjunction with these events. I further give my permission for the designated/approved church representative or sponsor to

secure any needed medical treatment for the above named son/daughter. I release the church representatives or sponsors from

liability for accident or injuries on these trips or activities.

I further understand and agree that, in the event that the above named son/daughter be involved in any dangerous or

inappropriate activities, I will pay his or her expenses to be sent home immediately at the discretion of the approved sponsors

and/or church representatives.

I understand & agree to all the information on this Medical Release Form.

Parent/Guardian Signature____________________________________________________Date ________________________

Student Signature___________________________________________________________Date ________________________

Medical Release Form