Second Presbyterian Church Medical Release Form
Valid 08-25/2019-08/24/2020
Email address *
We (I) am not aware of any medical condition of my child which would render inappropriate for him/her to participate in activities with youth group. We (I) are the parent(s) or legal guardian(s) of this participant and hereby grant permission for him/her to receive medical treatment, including but not limited to emergency surgery or medical treatment, be taken to a hospital, and/or travel in an ambulance should the need arise and assume the responsibility of all medical bills, if any. *
Parent(s)/Guardian(s) Name(s) *
Your answer
Child's Full Name *
Your answer
Known Medical Conditions/Allergies *
Your answer
Insurance Company and Policy Number *
Your answer
Name of Policy Holder and Relationship to Child *
Your answer
Insurance Company Phone Number *
Your answer
Parent/Guardian Full Name *
Your answer
Second Parent/Guardian Full Name
Your answer
Parent(s) Address(es) *
Your answer
Parent/Guardian phone number(s) *
Your answer
Second Parent/Guardian phone number(s)
Your answer
Alternate Emergency Contact Phone *
Your answer
Alternate Emergency Contact Name (Other than a Parent or Guardian) *
Your answer
Photo Release: I hereby authorize my child’s image or likeness to be reproduced or used for marketing, brochures, emails, Facebook, Twitter, and other social media sites, church and youth group websites, and for other uses as determined by church staff. *
I would like to be included in email updates *
Parent/Guardian Email Address *
Your answer
Second Parent/Guardian Email Address
Your answer
I would like to be included in text updates *
Parent/Guardian Cell Number *
Your answer
Second Parent/Guardian Cell Number
Your answer
I would like my child to receive text updates about youth activities *
Child Cell Number *
Your answer
Child Email Address (if they have one they check)
Your answer
Child's Birthdate *
MM
/
DD
/
YYYY
Child's Grade Fall of 2019 *
Child's School *
Your answer
Parent/Guardian Signature *
Your answer
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