2019 SonWest Vacation Bible School at Hutto Lutheran Church - Medical Release Form
Please fill out one medical release form per child participating.
Name of participant: *
Your answer
Parent(s)/Legal Guardian(s) Name: *
Your answer
I (we), the above stated parent(s) or guardian(s) of above stated participant, a minor, do hereby authorize adult volunteers of Hutto Lutheran Church as agent(s) for the above stated participant, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. Please electronically provide your signature by typing your name below. *
Your answer
Date: *
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I further release from liability Hutto Lutheran Church and any of its ministries or leaders in the event of an accident en route, during and returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence. Please electronically provide your signature by typing your name below. *
Your answer
Date: *
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Emergency contact other than yourself: (Name, number, relation) *
Your answer
Health Insurance Company
Your answer
Policy or Group Number
Your answer
List any allergies. Include medications, food, etc. *
Your answer
Does your child have any medical or special needs, including medications currently being used? *
Explanation to the above, if answered yes:
Your answer
Doctor Name and Number
Your answer
Dentist Name and Number
Your answer
Date of last tetanus shot
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