SVCC Medical Release
This form will take about 3-7 minutes to complete.You need the following information available to complete this form: General personal information, Primary and secondary emergency contact information, Health insurance carrier and doctor information
Participants's Information
Please fill out the required fields regarding this participant.
Participants Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
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Address
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Street Address
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City
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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New York
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Oregon
Pennsylvania
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South Carolina
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Tennessee
Texas
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State
Zip Code
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Parent/Guardian Contact
Please fill out the required fields regarding this parent/guardian.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
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Area Code
Phone Number
Parent/Guardian Email
*
Is this individual the primary emergency contact?
*
Yes
No
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Primary Emergency Contact
Please fill out the required fields regarding this primary emergency contact.
Primary Emergency Full Name
*
First Name
Last Name
Primary Emergency Relationship
*
Parent/Guardian
Sibling
Grandparent
Aunt/Uncle
Friend
Other
Primary Emergency Phone Number
*
-
Area Code
Phone Number
Primary Emergency Email
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Secondary Emergency Contact
Please fill out the required fields regarding this secondary emergency contact.
Secondary Emergency Full Name
*
First Name
Last Name
Secondary Emergency Relationship
*
Parent/Guardian
Sibling
Grandparent
Aunt/Uncle
Friend
Other
Secondary Emergency Phone Number
*
-
Area Code
Phone Number
Secondary Emergency Email
*
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Heath
Please fill out the required fields regarding this participant's health.
Health Insurance Carrier
*
Please Select
Aetna
Anthem Blue Cross
Blue Cross Blue Shield Association
Central California Alliance for Health
Cigna
Healthcomp
Health Net
Kaiser Foundation Group
Medi-cal
Medi-share
Santa Clara Family Health Plan
United Health Care
None
Other
Other Health Insurance Carrier
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Policy #
*
Family Doctor's Name
*
Doctor's Phone Number
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Area Code
Phone Number
Does your child have any concerning health conditions?
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Yes
No
Please describe any diagnosed health conditions:
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Does your child have any allergies to food, medications, insects, etc.?
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Yes
No
Please describe any diagnosed allergies:
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Date of Last Tetanus Booster
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Month
-
Day
Year
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Agreement
By completing this form, I hereby agree to the following: (I, We) hereby give permission for my child to participate in the Kids/Student Ministries activities of South Valley Community Church. (I, We), the undersigned parent(s)/person having legal custody/legal guardianship of the stated minor (s), do hereby authorize South Valley Community Church as agent for the hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority of power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnoses, treatment or hospital care which a physician, meeting the requirements of this authorization, may in the exercise of her/his best judgment, deem advisable. (I, We) hereby authorize any hospital which has provided treatment to the above-named minor(s) pursuant to the provision of Section 25:8 of the Civil Code of California to surrender physical custody of such minor to (my, our) above named agent upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California. These authorizations shall remain effective unless revoked in writing and delivered to SVCC. You understand the nature of our events and do hereby release South Valley Community Church or any of its representatives from any liability for the accidents or injury sustained by my child(ren) in conjunction with our events.
Signature (Parent/Legal Guardian)
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Name of Signature
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