Medical Info & Release Form - Online

North Central Youth Ministry Annual Medical Information and Release Form

Student Information
First Name
Middle
Last Name
Home Phone
Cell Phone
E-mail Address
Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Birthdate (mm/dd/yy)
School
Parent/Guardian (1)
First Name
Middle
Last Name
Relationship to Student
Parent/Guardian (2)
First Name
Middle
Last Name
Relationship to Student
Parent/Guardian (1) Address (or N/A)
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Parent/Guardian (2) Address (or N/A)
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Parent/Guardian (1) Home Phone (reply N/A if same)
Parent/Guardian (2) Home Phone (reply N/A if same)
Parent/Guardian (1) Cell Phone
Parent/Guardian (2) Cell Phone
Parent/Guardian (1) E-mail
Parent/Guardian (2) E-mail
Parent/Guardian (1) Employer
Parent/Guardian (2) Employer
Parent/Guardian (1) Work Phone
Parent/Guardian (2) Work Phone
Student Medical History and Information:
Allergies or Medical Conditions:
Current Medication:
Physician's Name and Phone Number:
Insurance Company:
Policy Number:
Parent/Guardian Alternate Numbers for Emergencies:

Please list three relatives or friends with phone numbers to contact in the unlikely event that parent or guardian could not be reached during an emergency.

Relative/Friend Name & Phone Number (1) Emergency Contact:
Relative/Friend Name & Phone Number (2) Emergency Contact:
Relative/Friend Name & Phone Number (3) Emergency Contact:

 

 

Parent/Guardian Consent for (Enter Name of Student):

I hereby give consent for the student listed above to participate in events sponsored by the North Central Church of Christ Youth Ministry during the calendar year. In case of an emergency and the unlikely event that I cannot be reached, I hereby authorize an adult chaperone to secure the necessary medical treatment at any registered hospital, clinic, or doctor's office as needed. I hereby relieve North Central Church of Christ and it's directors, supervisors, and sponsors from any and all liabilities for any and all sickness, accidents, and injuries and/or any other cause whatsoever while in attendance at a North Central Youth Ministry sponsored event.

Further, as a parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me and do further agree to hold blameless any physician, hospital, or other medical center for rendering such services.

AGREEMENT: By signing this Electronic Signature Consent Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. In executing an electronic signature by typing my name and submitting this document, I understand it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Parent/Guardian Electronic Signature

Date of Signature: