Loading...

Medical Power of Attorney/Liability Release Form and Medical/Insurance Information
Pleasant Hill Presbyterian Church
3700 Pleasant Hill Road
Duluth, GA 30096
770-497-0233

I do hereby extend and grant full authorization and power of attorney to the Rev. Jennie Sankey, Associate Pastor for Christian Education; Youth Group Advisers; or other designated adult event coordinators in attendance of Pleasant Hill Presbyterian Church for the purpose of: obtaining, permitting and authorizing medical and/or dental care and treatment, including surgery, and any other necessary medical or dental procedures, for an on behalf of my child while on an authorized activity with Pleasant Hill Presbyterian Church and such person or persons shall be full authorized and have full power of attorney on behalf of the undersigned to execute any and all consent forms, admission papers and any other documents attendant to procuring such necessary medical or dental care and treatment.

In addition, I hereby release Pleasant Hill Presbyterian Church, its staff, employees and volunteer leaders from any and all liability or from any and all claims, demands or causes of action related to injuries sustained by minor(s) during any authorized activity with Pleasant Hill Presbyterian Church.

This release and power of attorney shall be in full force and effect from August 22, 2021 through August 31, 2022.

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Parent or Guardian's Email Address
Email*
Confirm Email*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Doctor's Name
Doctor's Phone Number
Insurance Company
Insurance Policy Number
Insurance Group Number
Insurance Phone Number
Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)
Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)
Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!