Student Ministry 2021 Medical Release Form

Student Ministry 2021 Medical Release Form
Student's Name*
First NameLast Name
Current Grade*
School Student Attends *
Student's Email*
example@example.com
Student's Cell Number*
Please enter a valid phone number.
Student's Gender*
MaleFemale
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Parent/Guardian Name*
First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*
First NameLast Name
Phone Number*
Please enter a valid phone number.
Insurance Company
Claims To Be Mailed To
Policy or ID Number
Family Physician
Phone Number
Please enter a valid phone number.
Medications Currently Taking (list all, even vitamins)
List Allergies
Date of Last Tetanus Shot
MonthDayYear
Date
Permission to Give
IbuprofenAcetaminophenAspirin
Special Instructions Regarding Student
My child: Student's Name Here may participate in all Church Student Ministry events for the 2021 calendar year. As a parent or guardian, I authorize an adult counselor to make legal decisions, medical decisions, or otherwise concerning said minor during the time of Church Student Ministry events. I also agree that I will immediately notify Church Student Ministry, in writing, of any changes to the information above, medical or otherwise. I hereby release Church and its sponsors of any legal responsibilities and liability in the event of an accident or injury.

As a parent or guardian, I have carefully and truthfully provided all the information requested and give my permission for my child to participate in Church Student Ministry events in 2021.

Both my child and I understand that he/she will be expected to obey the rules, regulations and policies of Church Student Ministry events.
Parent/Guardian Signature*
Clear
Date
MonthDayYear
Date
Student Signature*
Clear
Date
MonthDayYear
Date
Should be Empty: