Child/youth Medical Release Form printable pdf download

CHILD/YOUTH MEDICAL RELEASE FORM

FIRST PRESBYTERIAN CHURCH

1028 S Belt line Rd, Mesquite, Texas 76149

(972) 285-5602

form

out ____

Date

filled

Name

Birthdate________________-

Address

Phone (

)

City

State

Zip

)

Social Security Number

(Is often required for treatment or admittance

Please

give

the last date for the following shots (children and youth

only):

Are immunizations current?

Polio

Tetanus.

DPT Series.

MMR

Physical problems/restrictions (e .g. allergies,

hyperactivity,

deafness, etc.) or special needs of child

Medications you

must

take:

- - - - - - - - - - - - - - - -

- - - - - - - - - -

- - - - - - -

Physician's Name - - -

- - - - - - - - - - - - -

Phone (

)

Medical Insurance

Company

Phone number (s) - -

- -

Policy Number or ID Number/Group Number

_______

PARENTS/GUARDIANS PLEASE

NOTE:

I understand

that,

in case of an

emergency,

every effort will be made to contact parents or

guardians. In the event that we cannot be reached, I hereby consent to emergency transportation, examination, x-ray, anesthesia,

injection,

Medical, dental, surgical diagnosis, treatment and hospital care as advised and administered by any physician, dentist, or

surgeon licensed to practice under

the

laws of the state where services are rendered, at a doctor's

office,

clinic or

hospital.

therefore,

assume all responsibility for

decisions made, and the emergency care or treatment so secured

for

my child. I further release First

the

Presbyterian Church,

its

staff and adult

leaders

from responsibility and liability for any injury or illness that

child may sustain during

church activity or transportation involving

church activity.

Also,

I understand that some hospitals require notarized authorization

the

before a child can be treated.

(If

this form is not signed and notarized a hospital may not treat a child/youth under age 18.)

Parent or Legal Guardian's Signature

Date

_ _ _ _ _

Parent or Legal Guardian's Name (Printed)

__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Work Phone

Cell

Pager

Other

case

of an emergency where

the

parent/guardian cannot be reached,

please call:

Name

Relationship

Phone

Signature of Parent or Legal Guardian

_ _ _ _ _ _ _

Executed before me this

Day of

_in the year of_____

State of

____________________

County of ___________________________________________

My Commission

Expires

Notary Public, State of Texas

COPY OF INSURANCE CARD (FRONT & BACK) ATTACHED TO THIS FORM IF POSSIBLE!***

***A

Child/youth Medical Release Form

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