2023-24 RGPC Medical Authorization Form

2023-24 RGPC Medical Authorization Form
Name of Youth

First NameLast Name
Youth's Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Cell Phone Number

Area CodePhone Number
Do you text?

YesNo
Parent/Guardian Email
example@example.com
Youth's Cell Phone Number

Area CodePhone Number
Allergies/Special Health Concerns/Medications/Dietary Needs
Date of Last Tetanus Shot

MonthDayYear
Date
Surgery or Serious Illness History
Physician’s Name

First NameLast Name
Physician’s Phone Number

Area CodePhone Number
Insurance Company
Insured's Name

First NameLast Name
Policy Number
ID Number
Employer's Name
Insurance Company Phone Number

Area CodePhone Number
Parents: My child may participate in activities with the above stated group, including travel during the event via church vehicle or private auto driven by an adult chaperone/leader with a valid driver’s license. I give permission for my child/myself to receive emergency medical care if necessary. I give the adult chaperones/leaders (Lisa Adams, Brad Avis, Katie Avis, Scott Benton, Melanie DeBeaudry, Joseph Harrison, Adam Hughes, Kate Mackie, Shannon Marzolf, Kellie Whitlock) the authority to act on my behalf with respect to my child’s/my own health and safety while at an event, with the understanding that I/emergency contact listed below will be contacted as soon as possible should the need arise. I accept full responsibility for any expenses for medical treatment for my child/myself. I release Rosedale Gardens Presbyterian Church and its representatives from liability in the event of accidental injury or illness. Effective Dates: September 1, 2023 through August 31, 2024. Electronic Signature (Parent/Guardian or Adult age 21 or over)

Clear
Printed Name

First NameLast Name
Date

MonthDayYear
Date
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Please upload the front and back of your medical insurance card or turn in a paper copy of each in the church office.
Browse Files

Cancelof
Browse Files

Cancelof
Photo Release

Parents & Adult Participants, please sign the following agreement:

I understand that participants’ names with contact information may be released only to other participants and the Rosedale Gardens Church office. I also understand that photos or videos of my child/myself, and possibly other family members, taken for church purposes, may be used for promotional purposes, including the church’s website and social, and historical records unless indicated otherwise here.
Contact Information

AcceptableNot Acceptable
Photo/Video

AcceptableNot Acceptable
Electronic Signature for Photo Release (Parent/Guardian or Adult age 21 or over)

Clear
Date

MonthDayYear
Date
Should be Empty: