Medical Release Form for Minor

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					   FEFC Medical Release Form for Minor
Name                                                    __DOB ____                     Age ______ Sex ______
Address ___                                             ______City                             Zip __________
In Emergency Notify:                                                         __________________________
Ph #1          ________________ Ph#2 _______________________ Ph#3 ____________________
Doctor:                                                         Phone                                __________
Date of last tetanus booster shot                     _____ Date of Last Physical                    _________
Allergic to: ______________________________________________________________________
Any medical needs
Medication presently being used
Limitations or restrictions while at activity
Insurance Comp/Policy #                                              ________________________________

In case of emergency, I understand that every effort will be made to contact me. If I cannot be
reached, I hereby give Fellowship 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 Fellowship Church and their designated representatives
from liability in acting on my behalf.

SIGNATURE OF PARENT/GUARDIAN                                         ___             __DATE                  __


Before me, the undersigned, a Notary Public in and for the state and county aforesaid, personally appeared
____________________________________________________ (the legal guardian of the aforementioned Participant),
with whom I am personally acquainted (or proved to me on the basis of satisfactory evidence), and who acknowledged
that he/she executed the foregoing instrument for the purposes therein contained.

        Witness my hand and seal, this ________ day of _____________________, 20____.

                                              Notary Public

My Commission Expires:

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