Medical Release 2024 - 2025

Participant Name *

Participant Date of Birth *

Grade *

Participant Gender *

Does Participant Attend Faith Church? *

Yes

No

Emergency Contact Name *

(Parent or Guardian for minor or Spouse or other contact for Adults)

Emergency Contact Phone Number *

Is participant covered by medical/hospital insurance? *

Yes

No

If yes - please list name of carrier

Carrier policy and or group number

HEALTH HISTORY

Allergies

Please check all that apply

Drugs

Asthma

Hay Fever

Insect Stings

Other

Other health conditions

Please check all that apply

Cardiac

Chronic Asthma

Nervous Disorder

Epilepsy

Physical Handicap

Diabetes

Mental Handicap

Seizure Disorder

Altitude Restrictions

Other

If you have checked ANY of the above, please give details

Please describe any activity restrictions

IMPORTANT

My child (or myself if adult) has permission to participate in all church events, except as noted above. I hereby give permission to the medical personnel selected by the Faith Church event director to order X-rays, routine tests and treatment for the health of my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician, nurse or dentist selected by the event director to hospitalize, secure proper treatment (including surgery, injection and/or anesthesia) for my child as named above, to include transportation to and from the necessary facilities. This health history is correct so far as I know.

I have read and acknowledge the above statement *

Signature of parent or guardian or adult volunteer/participant/staff *

Typing name below constitutes signature

Date *

Household members