MEDICAL RELEASE FORM

 

Name                                                                                                   Age                  Birthdate                                  

 

Address                                                                                                Home Phone #                                                 

 

City, State                                                                                             Zip Code                                                          

 

Parent’s Name:             Father                                                                           Mother                                                

 

Parent’s Work Phone #’s: Father                                                           Mother                                                            

           

Insurance Policy Holder’s Employer:                                                                                                                 

 

Insurance Policy Holder’s Social Security Number:                                                                                            

 

To Whom It May Concern:

Permission is granted for our (my) child,                                                                         , to attend and participate in activities sponsored by Pioneer Memorial Presbyterian Church.

 

We (I) also grant permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in such activities.

 

We (I) authorize an adult to whose care the minor has been entrusted to consent to any emergency medical/surgical procedure and to obtain medical prescriptions as necessary due to accident or illness, by a licensed physician or dentist.  We (I) will assume the responsibility for all medical bills, if any.

 

Further, should it be necessary for our (my) child to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all responsibility and transportation costs.

 

On the reverse side of this page, please list any allergies or special medical condition your child may have.

 

                                                                                                                                                                                   

^{Insurance Company                                                                                                      Youth’s Signature}

                                                                                                                                                                                   

^{Insurance Company Mailing Address                                                                              Mother’s Signature}

                                                                                                                                                                                   

^{Insurance Company Phone Number                                                                                 Father’s Signature}

                                                                                                                                                                                   

^{Policy Number/Group Number                                                                                       Legal Guardian (if any)}

                                                                                                                                                                                   

^{Physician’s Name & Number                                                                                        Date Signed}

                                                                                   

^{Additional Emergency Phone Number (if any)}                                                                                                              

 

(Please fill out the above information accurately and in detail.)

 

This form is valid from October 2004 through October 2005.

 

 

Pioneer Memorial Presbyterian Church

35100 Solon Road,

Solon, Ohio 44139

(440) 248-5260                                                                                                                          

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