Medical Release & Permission Form
Effective dates: January 1, 2005 to January 1, 2006
Please print in ink
General Information
Name (Last, First Middle): _________________________________________________
Age: ________ Birthday: ______________
Year in school: ______ Sex: __ Male __ Female. Email: ______________________
Address ________________________________________________
City ____________________________ State ______________________ Zip ________
Phone ________________________ Pager / cell _________________________
Medical insurance company_______________________________________________
Policy # __________________________
Mother's name ____________________________ Phone: Home ________ Work ________
Father’s name ____________________________ Phone: Home ________ Work ________
Emergency contact ________________________ Phone: Home ________ Work ________
Physician _________________________________Office phone _____________________
Dentist ___________________________________Office phone _____________________
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.
Check the following areas of concern for this student. If necessary, add another page with details:
- For your child’s safety and our knowledge, is your child a:
- Does your child have allergies to
- Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
- Date of last tetanus shot: _______________________
- Does your child wear:
- Please list and explain any major illnesses the child experienced during the last year:
Additional comments:
Should this child’s activities be restricted for any reason? Please explain:
Student Agreement
For your information, we expect each student to conform to these rules of conduct:
- No possession or use of alcohol, drugs, or tobacco
- No students can drive
- No fighting, weapons, fireworks, lighters, or explosives
- No offensive or immodest clothing
- No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
- Participation with the group is expected
- Respect property
- Respect one another, staff, and adult leaders
- Respect and comply with event schedules
Students who fail to comply with these expectations may be sent home at their parents’ expense. I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct.
Student signature: __________________________________________ Date: __________
Parental Agreement
Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, rollerskating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the DYCM prior to that event.
(Name of student) _______________________ has my permission to attend all youth activities sponsored by Our Savior Lutheran Church (herein after “the church”) from January 1, 2005 to January 1, 2006.
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Parent/guardian signature: ___________________________________ Date: ________