ECC Parental Consent & Medical Release ForM

Student's Name *
Student's Name
Address *
Address
Home Phone *
Home Phone
DOB *
DOB
Parent's Information
Guardian 1 *
Guardian 1
Cell Phone *
Cell Phone
Work Phone
Work Phone
Guardian 2
Guardian 2
Cell Phone
Cell Phone
Work Phone
Work Phone
Emergency Contact 1 *
Emergency Contact 1
Phone Number *
Phone Number
Emergency Contact 2
Emergency Contact 2
Phone Number
Phone Number
To Whom It May Concern
The undersigned does hereby give permission for my (our) child to attend and participate in activities sponsored by Eastside Christian Church. I (we) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis and/or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist at said hospital or dental office. I (we) authorize an adult, in whose care the minor has been entrusted, to consent to administer any over the counter medications approved below.* The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my (our) child to return home due to medical reasons or failure to comply with the guidelines of the activity, the undersigned shall assume all transportation costs. The Undersigned does also hereby give permission for my (our) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Eastside Christian Church.
Health Information
Hospital Insurance *
Immunizations Current? *
Phone Number
Phone Number
Does your child have allergies? *
Date of Last Tetanus Shot
Date of Last Tetanus Shot
*I (we) authorize that our student may be given the following over the counter medications by an adult in whose care my (our) student has been entrusted: *
Date *
Date
Date *
Date