Scribd
Upload
105 views1 page

Teen Medical

This document is a medical information and release form for First Federated Church student ministries activities from September 1, 2006 to September 1, 2007. It requires a student's name, contact information, medical details, insurance information, emergency contacts, and a parent's signature notarizing permission for the student to participate in activities and releasing the church from liability for any illness or injury.

Uploaded by

John C Stark
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
Download as doc, pdf, or txt
105 views1 page

Teen Medical

This document is a medical information and release form for First Federated Church student ministries activities from September 1, 2006 to September 1, 2007. It requires a student's name, contact information, medical details, insurance information, emergency contacts, and a parent's signature notarizing permission for the student to participate in activities and releasing the church from liability for any illness or injury.

Uploaded by

John C Stark
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
Download as doc, pdf, or txt
Download as doc, pdf, or txt
You are on page 1/ 1

FIRST FEDERATED CHURCH - STUDENT MINISTRIES

4801 Franklin Avenue, Des Moines, Iowa 50310

Medical Information and Release


For September 1, 2006-September 1, 2007

This form is valid for all First Federated Church (FFC) functions from September 1, 2006 to September 1, 2007. It must be
completed in full, signed by the parent/guardian of the youth and MUST BE NOTARIZED.

Student’s Name:____________________________________________________ Phone:___________________________________

Address:____________________________________________________________________________________________________
street city state zip
School:___________________________________________________ Grade:_________________ Age:______________________

MEDICAL INFORMATION

Allergies:___________________________________________________________________________________________________

Medication(s) Taken:__________________________________________________________________________________________

Physical Limitations:__________________________________________________________________________________________

Medical Insurance Company:___________________________________________________________________________________

Policy Holder’s Name:_________________________________________________ Policy #:________________________________

Parent’s Doctor:______________________________________________________ Phone #:________________________________

Student’s Doctor:_____________________________________________________ Phone #:________________________________

EMERGENCY PHONE NUMBERS


Parent/Guardian Name:_________________________________________ Home #:________________ Work #:________________

Parent/Guardian Name:_________________________________________ Home #:________________ Work #:________________

Other Person to Contact:_____________________________________________________ Phone #:__________________________

MEDICAL RELEASE

I give permission for _____________________________________ to participate in FFC’s student activities from September 1, 2006
to September 1, 2007. I hereby release FFC, its staff and sponsors from responsibility and liability for any illness or injury that the
above named child may sustain during any activity. In the event of an emergency, I hereby authorize an adult leader of the activity,
as agent for me, to consent to any x-ray examination; medical, dental, anesthetic, or surgical diagnosis; treatment; and hospital care
advised and supervised by a licensed physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state
where the services are to be rendered, either at the physician’s office or in a hospital. I understand the activity director will endeavor
to reach us should the nature of the injury or illness warrant it. However, we will not hold any of the activity personnel responsible if
efforts to contact me (us) are unsuccessful.

_______________________________________________________ _____________________
Signature of parent/guardian Date

(This portion must be filled out by the notary before returning to the youth office).
State of IOWA, County of______________________________

Subscribed and sworn to (or affirmed) before me this________ day of ________________, 20_______.

________________________________________________________
Signature and stamp of notary

You might also like