BCC Medical Release Form

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The purpose of this form is to provide accurate medical information about youth under the age of 18 who will be involved in an activity or activities sponsored by Buckeye Christian Church.

In addition, authorization for emergency medical treatment to be performed when it not possible to reach the parent/guardian is granted when this form is properly signed by the parent/guardian.

Email *

Record my email address with my response

Student Name: *

Address (Street, City, State, Zip): *

Date of Birth:

YYYY

Current medication being taken:

List of allergies (including food allergies):

List any medical conditions and what restrictions those impose of activities:

History of major illness or surgery (list the year of illness or surgery):

List any other pertinent medical information:

Health Insurance Company: *

Health Insurance Group #: *

Health Insurance ID# *

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