Name of District
Name of participant:
Gender
Address
Email Address:
Date of Birth
Grade just completed
Home telephone number
Name of Local Church
Name of Youth Leader
Parent, legal guardian, or other person who has legal authority to authorize medical treatment to participant in case of emergency. Please contact (list name)
Address
Home, work & cell telephone numbers
Health/Accident Insurance Carrier
Policy #
Group #
Personal Physician Name & Telephone Number
Physician Address
Please list any chronic or acute Medical problems. If none, state "None"
Please explain. (If you answered none to the above question, state "None")
Please list any known allergies (food, pollen, or medicine). If none, state "None"
List any medicatioins being taken at present and list their dosage instructions. If none, state "None"
I acknowledge the participant's immunizations are current
I or my child plans to attend the above identified Church Affiliated Activity, hereinafter referred to as "Church Affiliated Activity." I fully realize that injury or illness could result from or during my or my child's participation in the Church Affiliated Activity. In case of accident or illness, I give my permission to receive medical treatment as deemed appropriate. I will assume responsibility for any medical bills.
I, the parent or legal guardian have read the Authorization for Emergency Medical Treatment, General Release & Indemnification Form with full knowledge of its legal significance
I, the participant, have read the Authorization for Emergency Medical Treatment, General Release & Indemnification Form with full knowledge of its legal significance
I, the participant, have read the Assumption of Risk & Release & Medical Authorization for Lakeview Conference Center, Waxahachie, TX
Date
Name & relationship to participant
Phone Number(s)
Emergency Contact & Phone Number
Allergies/Medical Conditions/Activity Restrictions. If none, state none.
