Youth & Family Ministry - Medical Release Form 2024

Your name *

Email address *

Student Identification Information

Address *

Student Medical Information

Primary Insurance Company *

Primary Insurance Numbers & Group *

Physician Phone Number

Allergies *

None

Other

Does your child experience: *

None

Asthma

Headaches

Epilepsy/Seizure Disorder

Heart Trouble

Diabetes

Frequent Stomach Upset

Physical Handicap

Other

Has your child undergone these surgeries? *

None

Abdominal

Heart

Lung

Neurological

Other

Current Medications *

None

Other

Indicate your child's swimming ability. *

Medical note

Record additional medical concerns or information.

Medical Release Statement

I understand that there are inherent risks involved in any ministry or athletic event, and I hereby release and agree to indemnify the Church, its pastors, employees, agents and volunteer workers from any and all liability for injury, loss, or damage to person or property that may occur during the course of my child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I also agree to bring my child home at my expense should they become ill or if deemed necessary by the student ministries staff member.

I have read and understood the Medical Release Statement provided above, and I affirm its contents. *

Parent Signature #1 *

By typing your full name below, you provide a digital signature to affirm the veracity of the above information.

Parent Signature #2

By typing your full name below, you provide a digital signature to affirm the veracity of the above information.

Student Identification Information

Student Medical Information

Medical Release Statement

Parent Signature(s)