Medical Release Form

Teens For Christ l PO Box 920, Hudson, WI 54016 l 715-386-2549 l www.teens4christ.com
Medical Release Form

Fill out your medical information carefully
Name

First NameLast Name
Male/Female
Phone Number
Format: (000) 000-0000.
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent Information
Mother's Name

First NameLast Name
Phone
Format: (000) 000-0000.
Father's Name

First NameLast Name
Phone
Format: (000) 000-0000.
Email
example@example.com
In Case of Emergency and parents cannot be reached
Emergency Contact

First NameLast Name
Phone
Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Phone
Format: (000) 000-0000.
General Medical History
Attach medical information if applicable

Browse Files

Cancelof
Does your child have any food, medication or environmental allergies?
Allergies? Check all that apply
Please list and explain any allergies
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
Is any medication required?
Name and exact dose of medications that your child is taking. Please state the reason for taking it. (For example: 20 mg. Zoloft taken every morning, for depression).
In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate?
Please describe
In the event that the child care program must be evacuated, are there medications or supplies that must be taken with this child
Please describe
Name) First Name* Last Name* has my permission to take the following over-the-counter medicines for the following reasons:
1. Tylenol or Ibuprofen for headaches, pain, or fever
2. Benadryl, Calamine, or Caladryl lotions for insect bite/skin irritation-
3. Antacids (Tums or Pepto Bismal) for upset stomach-
4. Antibiotic creams such as Bacitracin for cuts and scrapes-
5. Vitamin C or Lozenges
Other approved OTC Medications
Medical insurance details
Name of Insurance Company:
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Policy/ID Number:
Group Number:
Expiry Date:

DayMonthYear
Physical Examination
Height:
Weight:
I hereby give my permission to medical personnel or staff members with proper credentials to give emergency medical treatment and care to the above named program participant and to administer any above-approved medication.
Signature
This medical release form is valid for the following events from 1-1-2024 thorough 12-31-2024:
Should be Empty:

Medical Release Form

In Case of Emergency and parents cannot be reached

General Medical History

Medical insurance details

Physical Examination