Medical Release

The following information is necessary to help avoid injury, and for rendering adequate and appropriate medical attention in the case of an accident. This information is confidential with access given only to facilitators who will be working with the said individuals and to qualified medical technicians in the case of an accident. This information will be adequate for the year of 2025.

Your name *

Email address *

Parent/Guardian *

Relation to Student *

Phone Number *

Address *

Emergency Contact *

Is Emergency Contact someone other than Guardian?

Yes

Health Insurance Company *

Insurance Phone # *

Member ID *

Group ID # *

Current Medications

Please list any medication you are currently taking (prescribes and/or not prescribed, dosage, frequency, and reason

On Site Medications *

In the event of injury, head ache, or need, I allow my student to be given the following

Ibuprofen

Tylonol

Dietary Restrictions

Concerns

Any physical disabilities, health concerns/limitations, allergies, reactions to medication:

Other

Is there any other helpful information you would like us to know about your student

Behavior Agreement *

I understand that in the case of excessive delinquent unacceptable behavior and in the judgment of the Youth Leader, I am responsible for the removal of my child from event upon request. No refund will be given for event fees.

Medical Agreement *

In agreement to the medical disclosure of the policy of Calvary Fellowship Gig Harbor, I have disclosed to the best of my knowledge all pertinent information for my child’s personal safety and appropriate medical attention. In case of emergency, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the physician selected by the Youth Leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, X-rays, or injections of medications for my child.

Parental Signature *

Enter Full Name

Today's Date *

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