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Home
Sermons
Learn More
Identity & Beliefs
Worship
Kid Squad
Outreach & Missions
Our Team
Volunteer
Community Groups
Eastside Students
Events/Sign-ups
Pathway
Day of Service
RightNow Media
AXIA
VBS
CIY MOVE
CIY MIX
Camp Scholarship Request
Eastside Medical Release Form
Give
Eastside Medical Release Form
ECC Parental Consent & Medical Release ForM
Student's Name
*
Student's Name
First Name
Last Name
Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
Home Phone
(###)
###
####
Age
*
DOB
*
DOB
MM
DD
YYYY
School
*
Grade
*
Parent's Information
Guardian 1
*
Guardian 1
First Name
Last Name
Relation to student
Cell Phone
*
Cell Phone
(###)
###
####
Work Phone
Work Phone
(###)
###
####
Guardian 2
Guardian 2
First Name
Last Name
Relation to Student
Cell Phone
Cell Phone
(###)
###
####
Work Phone
Work Phone
(###)
###
####
Emergency Contact 1
*
Emergency Contact 1
First Name
Last Name
Relation to Student
Phone Number
*
Phone Number
(###)
###
####
Emergency Contact 2
Emergency Contact 2
First Name
Last Name
Relation to Student
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
*
Yes
No
Immunizations Current?
*
Yes
No
Insurance Company
*
Name of Subscriber
*
Employer
Group Number
ID#
Family Physician
City
Phone Number
Phone Number
(###)
###
####
Does your child have allergies?
*
Yes
No
Please specify allergies, including adverse reactions:
Please specify any adverse reactions to medications:
Medical History
Please list any medications (dose and freq.) student is currently taking including non-prescription medications and any herbals/vitamins
Surgical History
Date of Last Tetanus Shot
Date of Last Tetanus Shot
MM
DD
YYYY
*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:
*
Acetaminophen (e.g. Tylenol)
Ibuprofen (e.g. Advil)
Diphenhydramine (e.g. Benadryl)
Cetirizine HCL (e.g. Zyrtec)
Midol
Dramamine
Antacid (e.g. Tums)
Other
Participant's Signature
*
Date
*
Date
MM
DD
YYYY
Parent or Guardian's Signature
*
Date
*
Date
MM
DD
YYYY
The undersigned does hereby release, forever discharge and agree to hold harmless Eastside Christian Church, its pastors, directors, employees, volunteers and teachers from any and all liability, claims and demands, for accidental personal injury sickness and death as well as property damage and expenses, of any nature what so ever that may be incurred by the undersigned and the participant while involved in the youth activities. I also 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.
*
Thank you!
