Contact and Medical Form

Contact and Medical Information for Wild Wednesdays at
One Community Church at 57 W. Elm Street, Monroe, OH 45050.

Parent: Please fill out the information below for each child enrolled in the
Wild Wednesdays!

Child Information
Child's First Name
Child's Last Name
Grade
School
Severe Allergies to
Food Allergies to
Other Information that would be helpful about your child
Photo Release: My child's photo/video footage may be used for publicity purposes for the Kids Musical Theatre Workshop and One Community Church.

YesNo

Parent & Contact Information
Father's Name
Father's Address, City, State, Zip
Father's Email
Father's Preferred Phone Number
Please enter a valid phone number.
Mother's Name
Mother's Address, City, State, Zip
Mother's Email
Mother's Preferred Phone Number
Please enter a valid phone number.
Emergency Contact Name:
Phone
Relationship to Child
Child Pick Up: List anyone who may be picking up your child other than the parents. (Picture ID required).
Name and Relationship to Child Pick-Up Person:
Name and Relationship to Child Pick-Up Person:

Medical Release Form
In the event of a medical emergency, I herewith authorize treatment under the direction of any licensed physician of the above minor child. The authority is granted only after a reasonable effort to reach me by phone at the number listed on the other side of this form has been made. The undersigned assumes the responsibility for any cost and releases One Community Church from any liability. This release is signed on my own free will with the sole purpose of providing medical treatment under emergency circumstances in my absence.
Family Physician
Physician Phone Number
Please enter a valid phone number.
Special Instructions
Parent Signature (Click and hold mouse button to sign)

Clear
In the event of a medical emergency, I herewith authorize transportion of the above minor child to my preferred or nearest hospital. The authority is granted only after a reasonable effort to reach me by phone at the number listed on the other side of this form has been made. The undersigned assumes the responsibility for any cost and releases One Community Church from any liability. This release is signed on my own free will with the sole purpose of providing medical treatment under emergency circumstances in my absence.
Preferred Hospital
Special Instructions
Parent Signature (Click and hold mouse button to sign)

Clear
Should be Empty: