Ecc youth medical release 12-13

Excelsior Covenant Church Student Ministries Valid September 1, 2012-Agust 31, 2013 AUTHORIZATION FOR EMERGENCY MEDICAL CARE TO A MINOR
I/we the undersigned parent(s) or legal guardian(s) of the minor listed below: First: ______________________________ MI: _____ Last: ________________________________ Address: _________________________________________________________________________ City: _______________________________ ST: _____ Zip: _________________________________ Home Phone: (______) ________________ parent’s email:_________________________________ Age: ________ D.O.B. (day/ month/ year): ____/____/____ Grade: _________ School: _______________________ Student Cell#_____________________ Txt msgs __Y __N Do hereby authorize any necessary examination, anesthetic, dental or surgical diagnosis or treatment by a duly licensed physician or dentist, or at a hospital licensed in the USA. I/We Authorize the physician or dentist to call in any necessary consultants at his/her best judgment as to the requirements of such diagnosis or medical, dental, or surgical treatment. It is further understood that those persons who have temporary custody of said minor will attempt to talk with the parent(s)/ legal guardian(s) via the telephone numbers listed before treatment is rendered. ____________________________________________
Home Phone: (_____) ___________________ Mobile Phone: (_____) ____________________
Work Phone: (_____) ___________________ Work Phone 2: (_____) ____________________
Please list any Allergies: ____________________________________________________________
Please list any medications and information regarding those prescriptions: _____________________
________________________________________________________________________________
________________________________________________________________________________
Does your child have diabetes, hypoglycemia, medical or behavioral disorders of which the adult
youth leader should be aware? ______________________________________________________
Does your child have a history of seizures? Yes_____ No_____
Is your child a proficient swimmer? Yes_____ No_____
Please provide any other helpful health information: _______________________________________
________________________________________________________________________________
________________________________________________________________________________
MEDICAL INSURANCE COMPANY: _____________________________ Policy # ______________
Contact Person (other than parent in case you cannot be contacted):
(Name) Relationship to your son/ daughter: ____________________________________________________ Download this Release Form at www.excelcovyouth.org Excelsior Covenant Church Student Ministries Valid September 1, 2012-Agust 31, 2013 Release of Liability
I/We undersigned parent(s)/ legal guardian(s) of _______________________________ , do hereby release and agree to hold harmless Excelsior Covenant Church and any related member, employee, sponsor or agent from any liability, injury, damages, loss, accidents, or delay to the listed minor’s planned participating in Excelsior Covenant Church sponsored events occurring between September 1, 2012 through August 31, 2013. This release covers all rights and actions of every kind, nature, and description, which the minor an his/her parent(s)/ legal guardian(s) ever had, now has or but for the release may have. I further authorize Excelsior Covenant Church to use photos or video taken of my child during ECC ministry events for promotional purposes. _____________________________________ ______________ _______________________ Signature of Parent/ Guardian _____________________________________ ______________ _______________________ Signature of Parent/ Guardian Over-The-Counter Medication Release (optional)
By indicating “Y” beside the listed over-the-counter medications and signing below, I authorize a representative of Excelsior Covenant Church and/ or medical professionals to administer said medication in accordance with label instructions if requested by my child Advil ____ _____________________________________ ______________ _______________________ Signature of Parent/ Guardian Received: __________ Recorded: __________ Please Return Completed Forms To The Youth Ministry Mailbox Outside the High School Room

Source: http://www.excelcov.org/storage/ECC%20Youth%20Medical%20Release%2012-13.pdf