Medical Form

A Medical Release Form for Minor Children is required for each child attending Vacation Bible School 2021 at Hope Presbyterian Church.

ONLINE MEDICAL RELEASE FORM FOR MINOR CHILDREN

Needed for a minor to participate in a special activity

Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Age*
Sex*
- Male
- Female
Address*
Street Address City ZIP / Postal Code
In case of emergency contact*
Phone 1*
Phone 2
Phone 3
Doctor's Name*
First Last
Doctor's Phone*
Date of last tetanus booster shot*
Date of last physical*
Allergic to (reply NONE if no allergies)*
Any medical needs? (Reply NONE if no special needs)*
Medication presently being used (reply NONE if no meds)*
Limitations or restrictions while at activity (reply NONE if no restrictions)*
Insurance Compancy/Policy #
Consent*
In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give Hope Presbyterian Church permission to act on my behalf in seeking emergency treatment for my child in the event the representatives of the church deem such treatment necessary. I give permission to those administering emergency medical treatment to do so, using those measures deemed necessary. I absolve Hope Presbyterian Church and their designated representatives from liability in acting on my behalf.
I agree.
Name of Parent/Guardian submitting this form*
First Last
Date of submission*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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