HOME Calendar GIVE CONTACT

WORSHIP SERVICES CHILDREN, YOUTH & FAMILY MINISTRIES SMALL GROUP STUDY

WHAT WE BELIEVE STAFF WELCOME OUR HISTORY OUR DENOMINATION

BODY & SOUL FITNESS CLASS FOOD ASSISTANCE MARRIAGE & FAMILY HELP PREGNANCY

CHURCH OPPORTUNITIES HELP YOUR COMMUNITY MISSIONS

BULLETIN ANNOUNCEMENTS COMMUNICATION CARD CONSENT FOR USE OF PHOTOGRAPHS INFORMED CONSENT MEDICAL RELEASE FORM PARENTAL CONSENT STATEMENT FORM PURCHASE ORDER FORM ROOM RESERVATION FORM VOLUNTEER PERSONNEL FORM

BULLETINS LEADERSHIP PAST SERMONS SERMONS - VIDEO SERMON NOTES SERMON STUDY GUIDES DIRECTORIES / REPORTS Sunday Morning Service Schedule

HOME Calendar MINISTRIES WORSHIP SERVICES CHILDREN, YOUTH & FAMILY MINISTRIES SMALL GROUP STUDY ABOUT WHAT WE BELIEVE STAFF WELCOME OUR HISTORY OUR DENOMINATION GIVE COMMUNITY BODY & SOUL FITNESS CLASS FOOD ASSISTANCE MARRIAGE & FAMILY HELP PREGNANCY SERVE CHURCH OPPORTUNITIES HELP YOUR COMMUNITY MISSIONS FORMS & DOCUMENTS BULLETIN ANNOUNCEMENTS COMMUNICATION CARD CONSENT FOR USE OF PHOTOGRAPHS INFORMED CONSENT MEDICAL RELEASE FORM PARENTAL CONSENT STATEMENT FORM PURCHASE ORDER FORM ROOM RESERVATION FORM VOLUNTEER PERSONNEL FORM CONTENT BULLETINS LEADERSHIP PAST SERMONS SERMONS - VIDEO SERMON NOTES SERMON STUDY GUIDES DIRECTORIES / REPORTS Sunday Morning Service Schedule CONTACT

MEDICAL RELEASE FORM

Downloadable paper copy: click here

Student's Name: *

First Name

Last Name

Date of Birth:

YYYY

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Name:

Address (if different from child):

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company:

Insurance Policy Number:

Please list the child's allergies (please check all that apply):

Bees

Hay/Straw

Pollen

Penicillin

Other Medications (please list below)

Other Items (please list below)

If allergic to other items, please list below and what the reaction is:

Does your child have any life-threatening allergies?

Yes

If yes, please list:

Is your child bringing any medication with him/her?

Yes

If yes, please list what medications and the dosage:

PLEASE NOTE: Medication should be in its original prescription bottle/package, which should have administration instructions and the child’s name clearly indicated.

Does your child have any physical, emotional, mental or behavior concerns or limitations that our staff should be aware of?

Yes

If yes, please explain:

Has your child had any of the following:

Seizures

Asthma

Diabetes

Homesickness

Heart Disease

Other (please explain below)

If other, please explain:

Date of Last Tetanus Shot:

YYYY

In the case of a medical emergency, I understand that hospital policy requires parental permission before treatment. I hereby give my permission to a representative of the Evangelical Free Church of Redwood Falls to administer medication as identified above and to secure proper medical treatment: Parents will be notified immediately of any medical emergency.

Signature of Parent/Guardian:

Date:

YYYY

Emergency Contact (in event parent/guardian cannot be reached:)

First Name

Last Name

Relationship:

Emergency Contact Phone:

(###)

###

####

Thank you!