Medical Release And General Permission Form printable pdf download

MEDICAL RELEASE AND GENERAL PERMISSION FORM - Helping Hands Day 2015

Please complete fully. Write “none” if a particular section does not apply to the participant. You must also include a copy of the

participant’s insurance card (front and back) with this form.

Name of Participant

_______________________________________________________________________

(please print)

Address _______________________________________________________________________________________

Phone Number __________________________________________________________________________________

Date of Birth _________________

Grade ____________

Age at event ______________

Gender_________

Participant’s Physician’s Name ________________________________________________________________________

Hospital/Clinic and Address __________________________________________________________________________

Phone Number __________________________________________________________________________________

1. Participant is allergic to (including food): ________________________________________________________

2. Please list any restrictions on diet or exercise: _______________________________________________

3. Does the participant have any special needs or medical history? If so, please list:

_______________________________________________________________________________

4. Are there any over the counter medications the participant can not receive?

_______________________________________________________________________________

5. Is the participant on regular medication? If so, please list the drugs, dosages, frequency and any instructions:

_______________________________________________________________________________

Please note that no drugs are to be brought to youth events other than those listed above

RELEASE OF ALL CLAIMS

In consideration of being accepted by the Southeastern Pennsylvania Synod, ELCA for participation in youth ministry events,

I (we) do for myself (ourselves) and on behalf of my child/participant do hereby release, forever discharge, and agree to

forever hold harmless the Southeastern Pennsylvania Synod, ELCA, the employees, and agents thereof, from any and all liability,

claims and demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever

which may be incurred by me or my child/participant resulting from said child’s participation in the synod sponsored youth events,

including travel, recreation and all associated activities.

Further, I (we) (and on behalf of our child/participant under 18 years of age) hereby assume all risk of said personal injury,

sickness, death, damage and expenses as a result of participation as above set forth. I also understand that staff and volunteers are

not responsible for the administration of prescribed medication and I (we) have made private arrangements for any medication taken on

a daily schedule by my child/participant.

I (we) am (are) the parent(s) or legal guardian(s) of this participant, and herby grant my (our) permission for him/her to

participate fully in said youth events, and give my (our) permission to take said participant to a doctor or hospital, share the above

medical information and authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and

assume responsibility of all medical bills incurred by my child.

I (we) give permission for the participant to receive over the counter medication such as Tylenol, ibuprofen, antidiahhreal

medication, antibacterial ointment, throat lozenges, eye wash solution, and the like.

I (we) also release the participant’s name as part of an information database for the synod and ELCA related entities. I (we)

also grant the synod and ELCA unrestricted rights to use, alter, and reproduce any images (still and video) from the event, in any

medium without compensation.

Parent’s/Guardian’s signature (if participant is registering as a youth):_____________________________________ Date: ________

Participant’s signature (if registering as adult participant):_______________________________________________ Date: _______

Emergency contact: _________________________________ Daytime Phone: _________________ Evening Phone: _____________

Medical Release And General Permission Form

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