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Loving God, Serving People, and Changing the World
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Children's Ministry Medical Release Form
Student's Name
*
First Name
Last Name
Gender
*
Male
Female
Birthdate
*
MM
DD
YYYY
Grade
*
Nursery
Toddler
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Student's Health History
Allergies and Health Conditions
Drug Allergies
Hay Fever
Food Allergies
Asthma
Insect Bites
Cardiac
Other
HEALTH CONDITIONS
Diabetes
Physical Disability
Nervous Disorder
Activity Restrictions
Chronic Asthma
Emotional Disability
Seizure Disorder
Epilepsy
Mental Health Issue
Special Concerns
Other
Details of all checked items
Please explain each of the areas checked and Please list all medications currently being taken
Parent Information
Mother's Name
*
First Name
Last Name
Mother's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother's Cell Phone
(###)
###
####
Mother's Email
Father's Name
*
First Name
Last Name
Father's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Father's Cell Phone
(###)
###
####
Father's Email
Emergency Contact
If parent's can not be reached
First Name
Last Name
Emergency Contact Cell Phone
(###)
###
####
Relationship
Insurance
Insurance Company
*
Policy Number
*
Primary Doctor's Name
First Name
Last Name
Primary Doctor's Number
(###)
###
####
Medical Release & Consent 1
I hereby waive all claims which I might have against La Jolla Presbyterian Church, their agents, and all employees for injury, accident, illness, or death occurring during or by reason of any and all ministry sponsored events that my child attends. I do hereby authorize La Jolla Presbyterian as agents for the undersigned to consent to any X-Ray examination, anesthetic, medical surgical diagnosis or treatment, and hospital care which is deemed advisable by and is rendered under the general or specific supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, where such diagnosis or treatment is rendered at the office of said physician or at the said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care required, but is given in advance to provide authority and power on the part of the aforesaid agents to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforesaid physician in the exercise of his/her best judgement may deem advisable. This authorization is given pursuant to the provision of Section 25.8 of the Civil Code of California. In consideration of and for the benefit to be derived by the undersigned here from, undersigned individually and or as a parent or guardian, for himself and/or themselves, his and/or their heirs, executors, administrators and assigns hereby released and forever discharge La Jolla Presbyterian Church, their officers, employees, servants, agents, and all persons connected with the above mentioned of and from all rights, claims, demands, and actions that may now or hereafter have, for any loss, damage, or injury sustained by the undersigned before, during, or after all church-relatied events, activities, or trips. Parent acknowledges that they have their own medical insurance and release La Jolla Presbyterian Church from all medical liability.
*
I accept and agree to the previous terms and conditions.
Digital Signature
I have agreed to submit this Medical Release and Consent Form by electronic means. By signing this Medical Release and Consent Form electronically, I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
*
Medical Release For acknowledgment and agreement
*
By selecting this button, I acknowledge that I have read and agree to the Medical and liability release form.
Yes, I have read and agree to the Medical and liability release form.
Thank you!
