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Children's Ministry Medical Release 2018-19
Medical Release
Email address *
Name *
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2018-19 *
Parent Info
Home address *
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Mother's Name *
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Cell Phone Number *
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Email Address *
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Father's Name *
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Cell Phone Number *
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Email Address *
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Medical Release
Insurance Carrier *
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Plan # *
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Doctor's Name & Phone Number
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In the event a parent is not available please give us an alternative emergency contact. *
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I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for Ascension Lutheran Church (hereafter “Designated Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. *
I understand the information above and by checking the box below I agree to electronically sign this form and Medical Release *
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