Medical Release and Permission Form If you prefer a hard copy, email Christine Eifert at efyouth@eastfairview.com. Youth Medical Release (1) 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Female Male Allergies/Medical ConditionsChild #2 Name* First Last Birth Date* Date Format: MM slash DD slash YYYY Gender* Female Male Allergies/Medical ConditionsChild #3 Name* First Last Birth Date* Date Format: MM slash DD slash YYYY Gender* Female Male Allergies/Medical ConditionsChild #4 Name* First Last Birth Date* Date Format: MM slash DD slash YYYY Gender* Female Male Allergies/Medical ConditionsAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Mother's Name First Last Mother's Mobile PhoneFather's Name First Last Father's Mobile PhoneEmergency Contact* First Last Emergency Contact Phone*PhysicianPhysician's Office PhoneI 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 SectionI 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.
