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2019 Medical Permission and Release Form
First Christian Church * 1100 Killarney Drive * Greenville, IL 62246

Permission for Treatment 

     My permission is granted for the minister or sponsor in charge to obtain necessary medical attention in case of sickness or injury to my child. I, the undersigned, do hereby verify that the above information is correct, and I do hereby release and forever discharge all sponsors and employees of First Christian Church from any and all claims, demand, actions, or causes of action past, present, or future, arising out of any damage or injury while participating in any and all 2017 activities.

     I, the undersigned parent/guardian, acknowledge that I am primarily responsible to any health care provider for services rendered to and on behalf of my minor children. I promise to pay such expenses and consent to our insurance company listed above to be billed. Further,

     I, the undersigned, agree to indemnify and hold harmless the Greenville First Christian church for any financial responsibility for any such medical care. 

Date: September 20, 2019

First Participant's Name

First Name*

Last Name*

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

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
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 or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Insurance

Insurance Carrier*

Insurance Policy Number*
Additional Information

Parent/Guardian name and phone #:

Parent/Guardian name and phone #:

In case of an emergency, notify (someone other than a parent): *

Phone # *

Relationship: *

Family Physician: *

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 or Guardian's Name

First Name*

Last Name*

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

Immunizations (date): 


Tetanus

Polio Booster

Measles

Mumps

Past Medical History

Check all that apply, giving appropriate information:
Asthma
Sinusitis
Bronchitis
Kidney Trouble
Heart Trouble
Diabetes
Dizziness
Stomach Upset
Hay Fever

Comments:

Allergies:


Foods:

Penicillin or other drug (name):

Insect Stings/Bites:

Other:

Previous operations or serious illnesses:

Any current medications you are taking (list):

Special Diet:
Childhood Diseases:
Chickenpox
Measles
Mumps
Whooping Cough
Other

If Other, please specify:
Parent 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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