Medical Release/History Form

Child/Dependent's Name

Date of Birth

Address

Phone

Parent/Guardian Name

Email of parent/guardian

This address will receive a confirmation email

Work Phone

Cell Phone

Physician's Name

Physician's Phone

Emergence Contact (if listed parent/guardian is unavailable)

Name

Relationship to Child

Phone

Address

Health History

Known Medical Problems:

Medications to be taken with directions:

Medication Allergies:

History of Asthma?

Yes No

History of seizures?

Yes No

History of heart problem?

Yes No

If yes, nature of problem:

May be given as necessary: Tylenol Ibuprofen

Last Tetanus shot (Td):

Health Insurance Company:

Group Number

ID Number

I hereby give my consent in advance to the designated leaders of Our Savior Lutheran Church and to the physicians or hospital selected by them to render emergency treatment as in their judgment is reasonably necessary, including, but no limited to, hospitalization, diagnosis including taking specimens and x-rays, giving blood transfusions and medications, anesthesia and surgery for my dependent listed above. I understand that the leaders of this activity will attempt to contact me before securing medical treatment, but that this consent is given in case I am not available in an emergency. I specifically release the leadership of this activity from any and all claims, loss, cost, damage or expense arising out of or from any accident or other occurrences causing injury to any person or property. (Signature of Parent/Guardian and Date

Description

Please fill out this form and click submit.

Medical Release/History Form

Description

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