INFORMATION AND MEDICAL RELEASE FORM
For all church-related activities of the Congregation Church of Birmingham, United Church of Christ, 100 Cranbrook Rd. Bloomfield Hills, MI 49304 - Phone:734.646.4511
Last Name *
Your answer
First Name *
Your answer
Birth Date *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Main Phone Number *
Your answer
Alternate Phone Number
This could be the parents or child's cell phone for example. Please enter who the phone number belongs to
Your answer
Main Email *
Your answer
Alternate Emails
This could be the child's email for example
Your answer
Grade Entering in September *
Your answer
HEALTH INFORMATION
Allergies to Medication *
Enter "None" if no Allergies
Your answer
Allergies to Food *
Enter None if no Allergies to food. Peanut Allergy? If yes please indicate if the student can self administer EPI pen
Your answer
Other Allergies
Your answer
Health Problems or Concerns
Your answer
Insurance Company
Your answer
Insurance Company Phone
Your answer
Policy #
Your answer
Policy Holder's ID #
Your answer
Doctor's Name and Phone Number
Your answer
PHOTO RELEASE FOR STUDENTS AND ADULTS *
I agree that video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the above named student during the activities may be used, distributed, or shown as the church sees fit
MINOR RELEASE (for minors only) *
I give permission for my child (name as listed above) to participate in the programs sponsored by the Congregational Church of Birmingham. This permission slip is valid for all activities held in association with the Congregational Church of Birmingham's Christian Education Program and other church related activities. I authorize my child to be transported to and from events in association with the Congregational Church of Birmingham, understanding that there may be only one adult in the vehicle and this adult will be at least 21 years of age. Specific information regarding church related activities will be distributed to the child or parents and is available from the Director of Christian Education. Special events may require additional permission forms.
PERMISSION FOR MEDICAL TREATMENT *
In the event of an emergency situation in which medical treatment is required for my child as a result of participation with the Congregational Church of Birmingham's church related programming, every reasonable effort will be made to contact the persons listed on this form. If unsuccessful in contacting the person listed, consent/permission is given for treatment by competent, medical personnel.
PERMISSION FOR HOSPITALIZATION *
Further, and unless specified otherwise, consent/permission is hereby given for the above named student to all accompanying adult volunteer leaders to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery (under recommendation of qualified medical personnel)
RESPONSIBILITY FOR MEDICAL EXPENSES *
I accept responsibilty for any medical expenses for my child that are not covered by my medical insurance. I will provide an updated Medical Release Form to the Director of Christian Education of the Congregational Church of Birmingham if and when any of the information provided on this form changes
ADULT RELEASE FORM (for those over 18 only)
Last Name of Adult
Your answer
First Name of Adult
Your answer
The above named adult is voluntarily participating in the programs sponsored by the Congregational Church of Birmingham. This permission slip is valid for all activities held in association with Congregational Church of Birmingham's Christian Education Program and other church related activities. In the event of an emergency situation in which medical treatment is required as a result of participation with Congregational Church of Birmingham's church related programming, every reasonable effort will be made to contact the persons listed on this form. If unsuccessful in contacting the person listed, consent/permission is given for treatment by competent medical personnel.
EMERGENCY CONTACTS
In the event of an emergency, contact:
Primary Emergency Contact Name #1 *
(Parent, Spouse or Legal Guardian)
Your answer
Contact Phone Number during activity *
(Cell Phone, work phone, home phone)
Your answer
Email Address (if different from above)
Your answer
Relationship *
Primary Emergency Contact - Name #2
In the case that the contact listed above cannot be reached (Parent, Legal Guardian, Relative or Responsible Person)
Your answer
Contact Phone Number during activity
(Cell Phone, work phone, home phone)
Your answer
Relationship
SECONDARY EMERGENCY CONTACT:
In the case that the contacts listed above cannot be reached, please call:
Secondary Emergency Contact Name
(Parent , Legal Guardian, Relative or Responsible Person)
Your answer
Phone number during activity
(Cell Phone, work phone, home phone)
Your answer
Relationship
Please be aware that Congregational Church of Birmingham holds all records and forms in the utmost confidentiality for the purpose of protecting all people who participate in activites associated with the church's ministry. If you have any questions at any time about our privacy policy, our safety policy, church related programs, or the Christian Education Program, please contact the church office
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