Brickhouse Permission & Medical Release Form
This form is effective June 1, 2018 through May 31, 2019
Student #1 Name, Grade *
Your answer
Student #2 Name, Grade
Your answer
Student #3 Name, Grade
Your answer
Student #4 Name, Grade
Your answer
Parent or Guardian Name *
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Home Phone
Your answer
Parent or Guardian Cell
Your answer
Best time to contact you
Your answer
I give permission for my above named student(s) to participate in all Brickhouse Student Ministry activities from June 1, 2018 to May 31, 2019. I hereby release Crossroads Community Church, its staff and sponsors, from responsibility and liability for any injury or illness that my child(ren) may sustain during these activities. In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me to consent to any X-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible. [Please type NAME and DATE below indicating signed consent] *
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Please list student allergies and medication below
Your answer
Medical Insurance Carrier
Your answer
Policy Number
Your answer
Member's Name
Your answer
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