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Medical Release and Permission Form
If you prefer a hard copy, email
office@eastfairview.com
.
Youth Medical Release Form
This is the youth medical and permission form. Information provided in this form will be kept private and not shared with anyone without permission unless medically necessary.
How many youth are you registering?
*
Please enter a number from
1
to
4
.
Child #1 Name
*
First
Last
Birth Date
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Female
Male
Allergies/Medical Conditions
Child #2 Name
*
First
Last
Birth Date
*
MM slash DD slash YYYY
Gender
*
Female
Male
Allergies/Medical Conditions
Child #3 Name
*
First
Last
Birth Date
*
MM slash DD slash YYYY
Gender
*
Female
Male
Allergies/Medical Conditions
Child #4 Name
*
First
Last
Birth Date
*
MM slash DD slash YYYY
Gender
*
Female
Male
Allergies/Medical Conditions
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Mother's Name
First
Last
Mother's Mobile Phone
Father's Name
First
Last
Father's Mobile Phone
Emergency Contact
*
First
Last
Emergency Contact Phone
*
Physician
Physician's Office Phone
I authorize the youth designated health monitor to administer the following medication as needed ONLY:
Tylenol
Ibuprofen
Advil
Motrin
Aspirin
Benadryl (appropriate doses)
Antacid for stomach upset
Throat Lozenges
Orajel
Visine
Should your child's activities be restricted for any reason? If yes, please explain.
Should your children's activities be restricted for any reason? If yes, please explain.
Any additional information we should know about?
Student Section
I agree to the following rules of conduct:
*
No possession or use of alcohol, drugs, or tobacco
No students can drive without permission
No fighting, weapons, fireworks, lighters, or explosives
No offensive or immodest clothing
No boys in girl's sleeping quarters and no girls in boys' quarters
I will participate with the group
I will respect other's property
I will respect one another, staff, and adult leaders
Persons who fail to comply with these expectations may be sent home (students at their parents' expense)
I have read the rules of conduct, the above health evaluation, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct. (Type full name below)
*
By typing your name in the above box is the equivalent of a signature authorizing that you agree to the terms and you are who you claim to be.
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases East Fairview Church and its staff of any liability against personal losses of participant.
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 I/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. Inn 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 no 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. (Type name if participant is over 18. If under 18 then type name of Parent/guardian)
*
Typing your name in the above box is the equivalent of a signature authorizing that you agree to the terms and you are who you claim to be.
Δ