Medical Consent And Liability And Activity Release Form
Children's Name
*
Parent/Guardian Names
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upload Your Health Insurance Card (Front)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Your Health Insurance Card (Back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Health Insurance
We currently do not have health insurance
We have an active health insurance policy
We will have health insurance before this event, but not right now
Known Allergies
Please list who has what allergies
Known Medical Conditions
Any special medication or health circumstances we should know?
Last Tetanus Booster
*
Please Select
This Year
Last Year
Within 5 Years
More than 5 Years
Never
Not Applicable
Medical Providers
Family Physician Name
Family Physician Phone Number
Family Dentist Name
Family Dentist Phone Number
Emergency Contact
Who should we contact in the event of an emergency?
*
Terms and Conditions
Permission to attend various Lock-Ins or other Epiphany functions as required during the 2022-2023 school year. (This form will be kept on file for one year only. Forms expire in August, before the next school year begins).By signing below, I and my child/children agree to follow all instructions given to me by those in authority, realizing any insubordination or continuing discipline problems could result in being sent home.The undersigned parent gives Epiphany Lutheran Church & School consent to any x-ray examination, anesthesia, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of, any licensed physician/surgeon, whither such diagnosis or treatment is rendered at the office or said physician/surgeon or at a hospital.It is understood that this authorization is given in advance of any specific diagnosis, treatment of hospital care being required but is given to provide authority and power on the part of the aforesaid agents) to give specific consent to any and all such diagnosis, treatment or hospital care which aforementioned physician/surgeon in the exercise of his/her best judgment may deem advisable.If applicable; if traveling ( (We) grant permission for our son/daughter to travel in a personal automobile to any youth function. In case of emergency, (I) (We) authorize Epiphany Lutheran Church and School leaders/counselors to secure the services of the nearest physician and/or medical facilities, pending other arrangements by parent/guardians.(1) (We) release Epiphany Lutheran Church and School, its leaders, counselors and employees, jointly and singularly, from any and all liability for any injury that my son/daughter may receive while participating in any youth event.
Terms Agreement
*
I have read and agree to the terms.
Parent/Guardian Signature
Please type your name in full to sign.
Submit
Should be Empty: