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Student Medical and Travel Release Form 2019/20

The following health record must be filled out for each student by the parent or legal guardian. The student may not be a part of any College Church extracurricular activity until we have a completed form on file. A new form must be filled out at the beginning of each school year.  If you have any questions, please contact a College Church ministry staff member.

Treatment: In case of emergency, I hereby give permission to the physician selected by the College Church staff and/or assigned personnel to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for the student named above.

Punctuality: I agree that my student should be punctual for designated departure times. If my student is more than 15 minutes late for an announced departure, I understand that College Church may leave for the event without my student. I agree that it is my responsibility to ensure that my student is picked up at the designated time at the church. I understand that College Church reserves the right to exclude my student from future events if I am continually late in either dropping off or picking up my student.

Dated: December 10, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent's or Guardian's Email Address

Email*

Confirm Email*
Medical Insurance Information

Insurance Company

Phone

Address

City

Zip

Policy Number

Group Number

Insurance Card Holder
Parents/ Legal Guardian Info

1) Name: *

Contact Number *

Email *

2) Name:

Contact Number

Email
Emergency Contact Information (secondary to the Parents/Guardians above)

Name *

City *

Phone *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent's or Guardian's Name

First Name*

Last Name*

Phone*
Parent's or Guardian's Date of Birth*
Parent's or Guardian's Information

Current Grade *

Height *

Weight *

Hair Color *

Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of

Allergies

Drug allergies

Date of last tetanus shot

Student's Doctor's Name *

Doctor's Phone Number *
Parent's or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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