Eastside 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

YYYY

School *

Grade *

Parent's Information

Guardian 1 *

Guardian 1

First Name

Last Name

Relation to student

Cell Phone *

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Guardian 2

First Name

Last Name

Relation to Student

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Emergency Contact 1 *

Emergency Contact 1

First Name

Last Name

Relation to Student

Phone Number *

Phone Number

(###)

###

####

Emergency Contact 2

First Name

Last Name

Relation to Student

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

Immunizations Current? *

Yes

Insurance Company *

Name of Subscriber *

Employer

Group Number

ID#

Family Physician

City

Phone Number

(###)

###

####

Does your child have allergies? *

Yes

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

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

YYYY

Parent or Guardian's Signature *

Date *

Date

YYYY

ECC Parental Consent & Medical Release ForM