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GLAD YOUTH MINISTRIES YOUTH CONVENTION MEDICAL RELEASE FORM

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GLAD YOUTH MINISTRIES YOUTH CONVENTION MEDICAL RELEASE FORM Powered By Docstoc
					GLAD YOUTH MINISTRIES YOUTH CONVENTION MEDICAL RELEASE FORM
*This form is to be filled out and signed by the legal guardian.

PLEASE NOTE:
Refunds for ½ of payment will only be issued in emergency situations.

Student or Leader (Please circle one)
Registration/Statement of Health

*Anyone 18yrs old & above must have a pastor’s certification form stating they have been cleared with a
background check run by the church and cleared as a leader to attend.

STUDENT/LEADER

Name:______________________________________________Sex:            Male Female    Age:________________________
        (Last)                    (First)

Address:____________________________________________ City:_______________________St:____________Zip:__________

Home Phone: ______________________________Wk. Phone: _________________________Birth Date:__________________

Church: _____________________________________________City:__________________________________________________

Pastor:_______________________________________________Youth Pastor:__________________________________________


PARENT/ GUARDIAN INFORMATION

Name of Parent/ Guardian:_________________________________________________________________________________
                                          (Last)                                     (First)

Address: (if different than applicant): _______________________________________________________________________

City:________________________________________________St:___________________________Zip:______________________

Home Phone:_______________________________________Wk. Phone:____________________________________________

In Emergency Notify: ____________________________________________________________Relationship:______________

Day Phone:_________________________________________Night Phone:__________________________________________

Name of Physician:__________________________________Phone:________________________________________________

Do you carry Family Medical/ Hospital Insurance?      Yes No

Medical Insurance Carriers name:
Policy or Group #_____________________________________Phone:_______________________________________________
1. Has the applicant received the following immunizations?               3. Check all that apply to the applicant:

Diphtheria               yr. ___________________                         ______   Heart Trouble
Whooping Cough           yr. ___________________                         ______   Ear Trouble
Polio                    yr. ___________________                         ______   Hernia
Tetanus                  yr. ___________________                         ______   Lung Trouble
                                                                         ______   Diabetes
2. Has applicant had                                                     ______   Seizures
                                                                         ______   Bleeding/Clotting Trouble
Measles                  Yes   No                                        ______   Hypertension
Polio                    Yes   No                                        ______   Mononucleosis
Mumps                    Yes   No                                        ______   Allergies
Chicken Pox              Yes   No                                        ______   Asthma
Scarlet Fever            Yes   No


4. List all allergies: __________________________________________________________________________________________

___________________________________________________________________________________________________________


5. Please list any other conditions medical personnel should be aware of: ____________________________________

___________________________________________________________________________________________________________


6. List any medications which the applicant has brought to Convention: _____________________________________

___________________________________________________________________________________________________________

PERMISSION/AUTHORIZATION FOR TREATMENT OF MINOR

I understand that my child ________________________________ will be in the care of ____________________________ (name of
Pastor/Youth Pastor) of _______________________________ (Church City and Name) during the 2008 Gulf Latin American District
Assemblies of God Youth Convention to be held at the Grand Hyatt San Antonio, November 27th-29tth , 2008.

I understand that I, Legal Parent/Guardian/Leader am responsible for complete medical charges should injury/illness occur. I
understand that the Assemblies of God Gulf Latin American District Council’s policy will provide for emergency First Aid cover-
age as a courtesy, within its limits, but only if the Assemblies of God Gulf Latin American District Council has been informed of
the injury at Convention, and if the person receives medical treatment while at Convention. I hereby give permission to the
medical personnel selected by the Assemblies of God District Office Staff/Convention Staff, to order x-rays, routine tests, treat-
ment, to release any records necessary for insurance purposes; and to provide and arrange necessary related transportation
for the above-named applicant. In the event that I, the parent/guardian cannot be reached in any emergency I hereby
give permission to the selected physician to secure and administer treatment, including hospitalization, for the applicant
named above. To the best of my knowledge all history is correct. The person herein described has permission to engage in
all prescribed Convention activities except as noted. This complete form may be photocopied by our church to carry during
off-site free time. I also give my consent for use of photographs of the applicant in District promotional videos, publications
and/or their website.


_____________________________________              ______________________
Signature of Parent/Legal Guardian                         Date

LEADER’S AUTHORIZATION
To the best of my knowledge all history is correct. This complete form may be photocopied by our church to carry during off-
site free time. I also give my consent for use of photographs of myself in District promotional videos, publications and/or their
website.

____________________________________               ______________________
Signature of Applicant’s Leader                           Date

This completed form should be photocopied by the church to have on hand during transportation to and from Convention.

				
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