Children & Youth Medical Release Form

Children & Youth Medical Release Form

Each adult must fill out the information below completely. This form will be kept on file for one year as a medical release. If your medical or insurance information changes, please contact Pastor Brent Vicars or submit another online form to update your information.
Name*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Grade*

Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any Allergies your child may have:*
List any Medical Conditions your child may have:*
List any Medications your child is taking*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian Cell Phone Number*

Area CodePhone Number
Parent/Guardian 2 Cell Phone Number

Area CodePhone Number
Parent/Guardian Email*
example@example.com
Parent/Guardian 2 Email
example@example.com
Parent/Guardian Work Number

Area CodePhone Number
Parent/Guardian 2 Work Number

Area CodePhone Number
Emergency Contact*

First NameLast Name
Relation to Emergency Contact
Emergency Contact Phone Number*

Area CodePhone Number
Insurance Provider
Insurance Policy Number
Insurance Group Number
Consent Of Information

I hereby give my permission, for myself, to participate in an activity organized by Kennesaw Methodist Church (Kennesaw MC) on or off church campus. I hereby release, hold harmless and absolve Kennesaw MC, their officers, staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity.
Release of Liability*

YesNo
Signature*

Clear
I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Kennesaw MC staff or any adult counselor acting on behalf of Kennesaw MC with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate} licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital.
Consent to Medical Treatment

YesNo
Consent to Medical Treatment *

Clear
To the best of my knowledge, I have listed above all of my medical allergies, medications being taken, medical problems and other pertinent information.*

YesNo
Signature*

Clear
Finally, I agree that Kennesaw MC may tape or photograph me and record my Voice during their participation in the activity. I agree that Kennesaw MC will be able to use them, in whole or in part. whether In original or modified form in any manner or media, Including without limitation, for the purpose of advertising, promoting, and publishing the Kennesaw MC whether doing the activity or thereafter. I hereby release and discharge Kennesaw MC and an affiliated entities from any and all claims, demands, or causes of action that I shall in connection with the use and exercise of the rights granted in this release.
Media Release Consent*

YesNo
Signature*

Clear
Submitted Date*

MonthDayYear
Date
Should be Empty: