Medical Release Form – Grace Bakersfield

Health Release Form

Participant’s Name *

Street Address *

City *

Current Grade *

Phone Number: *

ACTIVITY:

I hereby grant permission for my child to participate in the activity of the Grace Assembly of God Church.

I understand that my child participates in these activities at their own risk and that the Grace Assembly of God Church and its adult supervisors are not liable for any injury personal or otherwise to my child or caused by my child. Should any problems arise concerning the behavior of my child that would require them to return home prior to the end of the activity, I will pay for his or her return or come pick my child up. I authorize the treatment, by a qualified and licensed medical doctor, of the minor listed above in the event of any medical emergency which, in the opinion of the attending physician, is necessary and I/we cannot be reached after a reasonable effort has been made to secure my personal consent.

I am responsible for any medical expenses. *

Signed: *

Date: *

(Parent or legal guardian)

Home Phone:

Work Phone:

Cell Phone:

Other Pertinent Contact Information:

Emergency Contacts:

1.) Name:

Relationship to Participant:

Cell Phone:

Home/Day Phone:

2.) Name:

Relationship to Participant:

Cell Phone:

Home/Day Phone:

Medical Insurance Co.

Phone:

Policy Number:

Primary Care Physician:

Address:

City:

State:

Zip Code:

Telephone Number:

Special Medical Conditions/Allergies/Chronic Illness/Any Other Conditions

Current Medications:

Any other information (special needs, concerns)