Medical/permission And Release Form printable pdf download

Medical/permission And Release Form

Medical/Permission and Release Form

This Form Is Valid For All Church-Sponsored Youth Activities

Church

Address:

Name:

Age:

SS#:

DOB:

Phone:

Address:

State:

Zip:

In Case of an Emergency Notify:

Relationship:

Phone:

Family Physician:

Phone:

Family Insurance Company:

Policy #:

Immunizations:  Tetanus  Polio Booster  Measles  Mumps  Other

Past Medical History: (Check giving appropriate information)

 Asthma  Sinusitis  Bronchitis  Kidney Trouble  Heart Trouble  Diabetes

 Dizziness  Hay Fever  Stomach Upset  Other

Allergies: Food(s):

Penicillin or Other Drug(s) (Name):

Insect Stings/Bites:

Poison Sumac, Ivy, or Oak:

Previous Operations or Serious Illness:

Any Current Medication(s) List:

Special Diet (Name):

Childhood Diseases:  Chickenpox  Measles  Mumps  Whooping Cough

 Other

Permission for Treatment:

My permission is granted for the

Church, Pastor, Minister

of Music, Youth, and other staff personnel or other adult(s) in charge to obtain

necessary medical attention in case of sickness or injury to my child.

I, the undersigned, do hereby verify that the above information is correct and I do

hereby release and forever discharge all sponsors and the

Church from any and all claims, demands, actions or causes of action, past, present, or

future arising out of any damage or injury while participating in a church-sponsored

youth activity.

Dated this

day of

, 20

in the state of

County of

___

Signature:

Relationship:

On this the

day of

, 20

personally known by me and in my presence,

executed the within and foregoing Medical/Permission and Release form. Witness my hand and

official seal.

My Commission Expires:

Notary Public

Medical/permission And Release Form

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