GENERAL AND MEDICAL RELEASE FORM
*****Student Version
Expires June 1, 2008
Student
Name__________________________________________________________________
Age__________________________
Date of Birth_________________________________
School attending Fall 2007 ______________________________ Grade entering Fall 2007 ____
Home
address_______________________________________________ Apt. #_____________
City_________________________________
State_________________
Zip code___________
Home
phone_____________________________ Student
cell___________________________
Student e-mail
address_____________________ Parent
e-mail address___________________
Father’s
name____________________________ Father’s
cell phone______________________
Mother’s
name____________________________
Mother’s cell phone_____________________
Emergency contact
name_________________________ ER
contact phone________________
T-shirt size (*all sizes
adult) ______________________
Doctor’s
name________________________________ Name of physician’s group_______________
Doctor’s
phone________________________ Doctor’s address______________________________
Name of medical insurance
company___________________________________________________
Name of
insured___________________________________ Employer________________________
SSN or driver’s license
number & state__________________________________________________
Policy
number___________________________ Group
number__________________________
Insurance company phone
number_____________________________________________________
Insurance company
address__________________________________________________________
HEALTH HISTORY
Allergies_______________ Insect stings__________________ Drugs________________
Other conditions: ___ Heart condition ___ Diabetes ___
Asthma
___ Frequent stomach upset ___
Epilepsy ___
Glasses or contacts
___ Hay fever ___
Hearing aids ___ Frequent colds
___ Physical handicap ___
Swimming restrictions ___
Activity restrictions
If you checked any of the
above, please give details (i.e. include normal treatment of allergic
reactions):______
________________________________________________________________________________________
Name, dosage, and schedule of
medications that must be taken:____________________________________
________________________________________________________________________________________
Date of last tetanus
shot__________________________ Given by____________________________
PARENT RESPONSIBILITY
It is the parent’s
responsibility to find out all details of church and trip activities, including
all Sunday and Wednesday events. Parents are responsible for knowing all
details of any off-campus trips, including trip location, departure and return
time. Parents are asked to read “Youth News,” regularly check e-mail or call
for specific details.
I accept these terms. Parent
initials_____________ Date________________________
INSURANCE
Our church’s insurance is
only secondary insurance. If you have medical insurance, your carrier will be
billed for medical charges in the case of illness or injury while your child is
on a church-related activity or trip. I assume all responsibility of all
medical bills.
I accept these terms.
Initials_______________ Date__________________________
In the event I am unable to
provide information during an emergency, I hereby give permission to the
medical professional selected by the church leadership to secure proper
treatment, including but not limited to: medical evaluation, medical injection,
anesthesia, surgery, and hospitalization for my child as deemed necessary.
I accept these terms.
Initials________________ Date_____________________________
***(PLEASE TURN OVER!)
MEDIA
By signing below I give
explicit permission for the First United Methodist Church of Oviedo and/or
I accept these terms.
Initials_____________ Date__________________________
LIABILITY
I have read and understand
this form. I certify the above-named student is my child (or under my legal
guardianship) and resides with me. I give my consent to him/her to attend and
participate in activities, functions and trips sponsored by the First United
Methodist Church of Oviedo. I assume all transportation costs, should it be
necessary for my child to return home due to medical or disciplinary actions.
I accept these terms.
Initials________________ Date______________________________
I do hereby release, forever
discharge, and agree to hold harmless the First United Methodist Church of Ovideo, its staff, youth leaders, chaperones and volunteers
thereof from any and all liability, claims or demands for personal injury, sickness
or death, as well as property damage and expenses of any natures whatsoever
which may be incurred while participating in any activity or trip. I assume all
risk of personal injury, sickness, death, damage and expense as a result of
participation in recreation and work activities involved therein by my child. I
understand by my signature that this form is both a binding medical and
liability release.
** SIGN ONLY IN THE PRESENCE OF CERTIFIED NOTARY
Signature___________________________________ Relationship to Student________________
Print name_____________________________________________________________________________
Date____________________________________________________________________________________
FOR
NOTARY SIGNATURE ONLY
Sworn to and subscribed before me this _________________ day of
_____________________, 20________
Notary Public
signature_____________________________________________________________________
State of______________________
My commission expires_________________
Print, type or stamp commissioned name of Notary Public:
The above signed is personally known to the Notary Public__________ or
produced identification_________
Type of identification
produced______________________________________________________________