Medical Release/Parent Authorization

Medical Release/Parent Authorization

Name of child First Name* Last Name* Date of Birth Date*

Allergies and Medical Conditions
Please list any of child's allergies/medical conditions:
Please list any symptoms/treatment for conditions:

Emergency Contact Information
Contact #1
Name   First Name   Last Name   Relationship
Phone   Area Code   Phone Number   Address   Street Address   Address Line 2   City   State   Zip
Contact #2
Name   First Name   Last Name   Relationship
Phone     Area Code   Phone Number       Address
    Street Address   Address Line 2   City   State  Zip

Insurance Information
Family Physician   First Name   Last Name
Physician Phone      Area Code   Phone Number
Name of Insurance Company         Policy Number
Contact Number      Area Code   Phone Number
Group Number

I, First Name* Last Name* , parent/guardian of First Name* Last Name* . a minor child, hereby authorize any medical or surgical treatment which may be necessary in an emergency or in my absence, for the well being of the above mentioned minor. I agree to hold harmless Eastgate Academy, Eastgate United Pentecostal Church, and/or any employee, volunteer or representative thereof. I agree to hold the physician, or hospital treating the above mentioned minor harmless.

Signature Signature* Date Date*