MedicalRelease Form

YOUTH  ACTIVITY  MEDICAL  RELEASE (scroll down for Word format)

This form is to remain in the possession of Adult Advisor at all times. 

NAME: _______________________________________  DATE OF BIRTH: ___________________

LOCAL CHURCH NAME AND ADDRESS: _____________________________________________

__________________________________________________________________________________

PARENT/GUARDIAN: ______________________________________________________________

HOME ADDRESS: __________________________________________________________________

HOME PHONE NUMBER: ___________________________ CELL: _________________________

SECOND PARENT/GUARDIAN or EMERGENCY CONTACT: _____________________________

ADDRESS: ___________________________________________  PHONE: ____________________

Dietary Restrictions: _________________________________________________________________

Allergies: _________________________________________ Date of Last Tetanus Shot: __________

Current Medications (please supply instructions): __________________________________________

Any treatments or medications to be continued while at retreat: _______________________________

Any activity restrictions while at retreat: _________________________________________________

Name of family physician: ___________________________________Phone: ________________

Address: ___________________________________________________________________________

Name of dentist/orthodontist:            ________________________________Phone: ________________

Address:___________________________________________________________________________

Do you carry family medical/hospital insurance?        Yes _______               No _______

Carrier: _______________________________________ Policy Number: _______________________

PLEASE ATTACH COPY OF INSURANCE CARD TO THIS FORM

            This health history is correct as far as I know, and the person herein described has permission to engage in all retreat activities except as noted.

            AUTHORIZATION for TREATMENT:  I hereby give permission to the medical personnel selected by the Adult Leaders of the above named local church to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my child.

            I hereby give PERMISSION FOR MY CHILD ____________________________________

TO ATTEND ______________________________________________________________________.

Signature of Parent/Guardian: ____________________________________________ Date: ________

Witness - Signature of Adult Advisor: ______________________________________ Date: ________