Medical Release Form

Student's Name *
First Name
Last Name
Home Address *
Address Line 1
Address Line 2
Postal Code
Date of birth*
Gender *
What school does your student attend?*
What grade is your student in?
Student Email
Parent Email
Student Phone Number
Medical Insurance Company
Insurance Policy Number
Mother's Name
First Name
Last Name
Mother's Email Address
Mother's Cell Phone Number
Mother's Work Number
Best way to contact mother? *
Father's Name
First Name
Last Name
Father's Email Address
Father's Cell Phone Number
Father's Work Number
Best way to contact father?
In the case of an emergency and neither parent can be reached, who do you want contacted?
First Name
Last Name
Emergency Contact Cell Phone
Physician's Office Number
Dentist's Office Number
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. Include names of medications and dosages that must be taken.
For your student's safety and our knowledge, what type of swimmer is your student?
Does your student have any allergies? If so please list them and any medication they may take for it.
Does your child suffer from, or has ever experienced, or is being treated currently for any of the following? (Please select all that apply.)
Date of last tetanus shot?
Does your child wear (please select all that apply.)
Please list and explain any major illnesses your student has experienced during the last year.
For your information, we expect each student to conform to these rules of conduct -No possession or use of alcohol, drugs, or tobacco -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.
Has your student read the above expectations and agree to abide by them?*
My student has my permission to attend all youth activities sponsored by Saltshaker Youth Ministry (hereinafter the “Church”) as of January 2018. If any information of this form changes after it is signed, we ask that you please inform Josh Hale as soon as possible. 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 Ministers, 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.
As the parent/gaurdian of this student, by typing your name below you agree that all information on this form is correct and agree to the terms on this Medical Release Form. *
First Name
Last Name