Permission, Discipline & Emergency Care Authorization Form
Each student must fill out the information below completely. This form will be kept on file until December 31st, 2024 as a medical release. If your medical or insurance information changes, please contact Brian Johnson or submit another online form to update your information.
Student's Name
*
First Name
Last Name
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Grade
*
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
Other
Student Email
example@example.com
Student Phone Number
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 1/ Guardian 1 Name
*
First Name
Last Name
Parent 1 Email
*
example@example.com
Cell Phone Number
*
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Parent 2/ Guardian 2 Name
First Name
Last Name
Parent 2 Email
example@example.com
Cell Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Emergency Contact (If parents cannot be contacted)
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Relation to Student
*
Permission
I, the undersigned, parent or legal guardian of the minor listed on this form, certify that he/she has my full approval to participate in any activity associated with First Christian Church. The undersigned named understands that all minors are expected to abide by the rules set forth by the church or its sponsors. The sponsors assume responsibility for discipline at events, and if necessary, may, at their sole discretion, because of misconduct or disobedience, require a student to leave. In such instance, I/we, as parent or guardian, will assume any and all expense and full responsibility for returning the minor home. Furthermore, I do release and hereby agree to hold harmless First Christian Church or its sponsors from any and ever claim arising, or which may be asserted by me, as parent/guardian, or by any member of my family by reason of participating in any activities associated with First Christian Church. I do hereby authorize any emergency treatment, X-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any physician or dentist licensed in the United States whether such diagnosis or treatment is rendered at the office of the physician or dentist or at a hospital licensed in the United States that may be rendered to said minor under the general, specific or special consent of any of the following representatives of First Christian Church, Stilwell, OK.
Signature
*
Parent / Guardian
Submitted Date
*
-
Month
-
Day
Year
Date
Health Insurance
I authorize the physician or dentist to call in any necessary consultants, in his/their discretion. I further authorize said physician or dentist to exercise his/their discretion in authorizing the disposal of any severed tissues or member.
Health Insurance?
*
Yes
No
Insurance Company
*
Policy #
*
Physician
Phone #
Allergies
Medications Currently Taking
Medical Release
It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgement as to the requirements of such diagnosis or medical or dental or surgical treatment. Further, it is understood that I will assume any financial responsibility for any expense that may be incurred for emergency treatment during the activities. This consent shall remain effective until December 31, 2024 unless sooner revoked in writing, delivered to said physician or dentist or said persons entrusted with the custody, care and control of said minor child. All parties signing this document hereby approve of all the terms and conditions listed herein and agree to be bound and governed by all provisions.
Signature
*
Submitted Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: