Fillable Printable Medical Release Form
Fillable Printable Medical Release Form
Medical Release Form
Medical Release Form – General
To be completed by all youth and adult participants of ministry outreach
.
Youth Group Coordinators, please keep originals with your files during trip.
Name:
Last First
Age: Date of Birth: _/ / School Grade in Spring
2012:
Gender:
[ ]F [ ]M [ ]Trans* (*If not out, please check the gender you usually present)
Email: Cell
Phone:_
Home
Church: Church City:
Primary Emergency Contact for youth (Parent/Guardian); for adults (Spouse/Partner/Family/Friend):
Name:
Cell number: Home/other contact number(s):
Other
Emergency
Contact:
Name:
_Relationship:
Cell
number(s):
Other
contact
number(s):
Health Insurance Company: Policy
#:
Group
#:_ Name of Policy
Holder:
Doctor’s
Name:
_Telephone:
Current
medications: List name, dosage, frequency. (if needed use additional sheet)
For Parents/Legal Guardian: [ ] Youth may self-administer above medications.
[ ] Group Coordinator or designated chaperone may assist as needed.
Permission is [ ] or is not [ ] granted [check one] for this youth to receive OTC medications from trip coordinator as
needed.
Parent/Legal
Guardian
initials
:
Health History: List all conditions, including but not limited to allergies, sleepwalking, convulsions, diabetes, mononu-
cleosis, epilepsy, mobility issues, emotional problems or hyperactivity, fatigue, headaches, dizziness. Please indicate how
long since last occurrence of problem. Use additional paper if necessary.
By signing this form I verify that the health/medical and insurance information provided on this form is true, accurate and
complete. In case of medical emergency, I give permission to the physician(s) selected by my/my youth’s group coordi-
nator to secure proper medical treatment for the participant named on this form. I agree to pay additional costs that arise
from such medical treatment if not covered by insurance.
Signature of Parent/Legal Guardian (for youth); or Adult Participant:
Jan.’12
IMPORTANT INSTRUCTIONS
A copy of this medical release form should be kept by the group coordinator
for youth. Adults are responsible for keeping a copy of these records on
their person.
ADDITIONALLY
Please email one PDF copy to mi[email protected].
(
*
along with one copy of all Covenants and Medical Release Form)
Staff Liaison: 216-736-3871
THANK YOU!
