Capital West Christian Church Medical Release Form
Permission, Discipline, & Emergency Care Authorization Form
Email address *
Students Name: *
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Students Birthdate: *
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Address: *
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I, the undersigned, parent or legal guardian of the minor listed on this form, certify that he/she has my full approval to participate in any activity associated with Capital West Christian Church. The undersigned named understands that all minors are expected to abide by the rules set forth by the church or its sponsors. The sponsors assume responsibility for discipline at events, and, if necessary, may, at their sole discretion, because of misconduct or disobedience, require a student to leave. In such instance, I/we, as parent or guardian, will assume any and all expense and full responsibility for returning the minor home.Furthermore, I do release and hereby agree to hold harmless Capital West Christian Church or its sponsors from any and every claim arising, or which may be asserted by me, as parent/guardian, or by any member of my family by reason of participating in any activities associated with Capital West Christian Church. I do hereby authorize any emergency treatment, X-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any physician or dentist licensed in the United States whether such diagnosis or treatment is rendered at the office of the physician or dentist or at a hospital licensed in the United States that may be rendered to said minor under the general, specific or special consent of any of the following representatives of Capital West Christian Church, Jefferson City, MO.
Health Insurance Company: *
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Health Insurance Policy Number: *
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Physicians Name: *
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Physicians Phone Number: *
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Students Allergies: *
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Medication Currently Taking: *
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Dietary Restrictions: *
Emergency Contact Information: *
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It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment. Further, it is understood that I will assume any financial responsibility for any expense that may be incurred for emergency treatment during the activities.
Parent/Guardian's Name: *
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Parent/Guardian's HOME PHONE Number: *
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Parent/Guardian's CELL PHONE Number: *
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Parent/Guardian's Address: *
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All parties signing this document hereby approve of all the terms and conditions listed herein and agree to be bound and governed by all provisions.
Date: *
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Electronic Signature: *
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A copy of your responses will be emailed to the address you provided.
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