MEDICAL CONSENT, LIABILITY AND ACTIVITY RELEASE FORM
Please type or print in ink.
PARTICIPANT NAME: (Last)_________________________ (First) ________________________ BIRTH DATE: / / MALE: FEMALE:
HOME ADDRESS: ________________________________________________________________ CITY/STATE/ZIP: _________________________________________________________________ HOME PHONE: ( ) _____________________ DAY PHONE: ( ) _____________________
CUSTODIAL PARENT/GUARDIAN: __________________________________________________ HOME PHONE: ( ) _____________________ DAY PHONE: ( ) _____________________ HOME ADDRESS (IF DIFFERENT)___________________________________________________ HEALTH PLAN CARRIER: _________________________________________________________ NAME OF INSURED: _____________________________________
RELATIONSHIP TO PARTICIPANT: __________________________________________________ INSURANCE ID NUMBER: _________________________________________________________ FAMILY DOCTOR: ________________________________________________________________ OFFICE PHONE: ( ) ____________________ MEDICAL EXCHANGE: ( OFFICE PHONE: ( )______________
FAMILY DENTIST: ________________________
)___________________
SECOND PARENT OR EMERGENCY CONTACT PERSON: ______________________________ RELATIONSHIP TO PARTICIPANT: __________________________________________________ HOME PHONE: ( ) _____________________ DAY PHONE: ( )______________________
Please specify emergency hospital preference as well as if any health insurance pre-certification, notification, or other requirements which exist for the participant: ____________________________ _______________________________________________________________________________ Please attach copies of Medical Card Copy Front and Medical Card Copy Back
EMERGENCY & HEALTH INFORMATION — To be completed by parent. Please explain any
“Yes” answers on the back of this page or on a separate page if more space is needed. Yes No Allergies? Yes No Heart Condition? Yes No Other? Is this youth subject to — (explain on back if “Yes”) Yes No Headaches? Yes No Seizures? Yes No Fainting? Yes No Sleepwalking? Yes No Upset Stomach? Yes No Other? Does this youth have reactions to or allergy to— (explain if “Yes”) Yes No Bee Sting? Yes No Poison Ivy, Oak, Sumac? Yes No Penicillin? Yes No Other Drugs? Yes No Other? Please indicate ANYTHING else which leaders should know to help avoid or deal with any situation which may arise:
Date of Last Tetanus Shot:
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Child’s Name
Your Relationship
AUTHORIZATION, CONSENT AND LIABILITY WAIVER
EMERGENCY PROCEDURE: In the event of any emergency, leaders will take whatever steps may be
necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to, the following: Attempt to contact a parent or guardian. Attempt to contact the youth’s physician. Attempt to contact you through any of the persons listed on the emergency information form above. f we cannot contact you or the youth’s physician we may do any or all of the following: Call another physician; call an ambulance; have the child taken to an emergency hospital in the company of a staff member. With this signed agreement I hereby authorize First Aid by PoP’s Student Ministry staff members or volunteers. I hereby authorize emergency medical care by hospital staff and/or doctors selected by youth group counselors. I
consent to medical, surgical and dental care for such minor child, (ii) consent to any diagnostic tests, medical, surgical or dental procedure or treatment as may be considered therapeutically necessary by the physician, surgeon, dentist or other health care personnel providing care for such minor child, and (iii) on (my) (our) behalf, to (a) employ physicians, surgeons, dentists, nurses, and other health care personnel as may be deemed necessary for such minor child,
I hereby consent to participation of my child in activities for the Student Ministry of Prince of Peace Lutheran Church & School (Prince of Peace). I release and forever discharge Prince of Peace, its agents and servants, successors and assigns, directors, trustees, officers, employees, and other representatives from any and all damages of my child’s participation in, attendance at, and travel to and from activities associated with the Student Ministry of Prince of Peace. Furthermore, I do hereby expressly stipulate, and agree to indemnify and hold forever harmless Prince of Peace, its agents and servants, successors and assigns, directors, trustees, officers, employees, and other representatives against loss from any and all present or future claims, demands, or actions in law or in equity that may hereafter be made or brought by me or my child, by anyone on behalf of me or my child, or by anyone else on their own behalf for damages or any other legal or equitable remedy on account of any injury, illness, physical condition, inconvenience, or loss sustained by me or my child during activities associated with the Student Ministry of Prince of Peace or travel to and from the same. In addition, by my signature I grant my permission to allow photographs/video taken during all youth group activities to be used for public relations purposes by the ministry of Prince of Peace Lutheran Church and School. I, the undersigned, hereby acknowledge that I have read the foregoing, understand its contents, and have signed the same as my own free act and deed.
Parent signature ______________________________ Name (please print) _______________________________
Date: ______________
Please attach copies of your medical insurance card. (front and back) Front Back
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