Medical Information and Liability/Media Release Form
This form will give necessary medical information for your child while they are under the supervision of Mount Pulaski Christian Church and the staff and volunteers associated with the church. This will also wave Mount Pulaski Christian Church and its staff and volunteers of liability while the child is under the supervision of Mount Pulaski Christian Church and its staff and volunteers.
Upon completion, this form will be good for exactly ONE YEAR. We will ask you to re-submit a form each year to make sure we have the most accurate information. If your information changes before next year, please let Garrett LeVault know as soon as possible.
If you feel uncomfortable filling out this form online, please email
and he will send you a paper version to fill out and return at your earliest convenience.
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This form was created inside of Mt Pulaski Christian Church.