ASBURY STUDENT MEDICAL RELEASE

Student's Name*

First NameLast Name

Date of Birth*

Date

Grade

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Student Email*

example@example.com

T-Shirt Size*

Emergency Contact*

First NameLast Name

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Contact*

First NameLast Name

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Insurance Company Name*

Insurance Company's NameFill in the word "Company" here

Policy NumberGroup #

CardholderRelationship to Cardholder

Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Company Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Physician's Name*

First NameLast Name

Physician's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):





Type a label

List ALL medication taken on a regular basis and/or any brought with you. (Prescription meds MUST have a pharmacy label and name of doctor.)





Type a label

List all operations/serious injuries and dates within the past five (5) years:

YES

PARENT/GUARDIAN AGREEMENT

As parent or legal guardian of the above-mentioned child, I hereby authorize any necessary medical and/or surgical care, including diagnosis and treatment, to be rendered to him/her by any licensed physician or surgeon, or by any licensed medical personnel, or by any licensed hospital, when authorized by Marcellus Campbell, Brian Hinnant, or any adult leader or helper of Youth Ministries at Asbury Church. We assume full financial responsibility for such care, including prescribed medications and transportation by ambulance and agree to make full payment for same upon receipt of statement of fees.

We do hereby, for a good and valuable consideration, agree to indemnify and hold harmless Asbury Church, its employees and Youth Ministry Programs, Marcellus Campbell, Brian Hinnant, leaders, chaperones, and sponsors from any and all actions, claims, demands, suits, or other liabilities which may result from the above-named minor’s participations in this event.

My child has permission to participate in the events described above. This agreement shall be valid for all activities concerning Asbury Student Ministry.

Signature*