Foundation Medical Release 2024

Foundation Medical Release 2024

An online medical release for Foundation Church. A new form must be completed every year. Effective dates January 1, 2024 - December 31, 2024
Student Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Grade (2023-2024)*
Gender*
2nd Student Name

First NameLast Name
Birthdate

MonthDayYear
Date
Grade (2023-2024)
Gender
3rd Student Name

First NameLast Name
Birthdate

MonthDayYear
Date
Grade (2023-2024)
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Email*
example@example.com
Parent Cell Phone*

Area CodePhone Number
2nd Parent Email
example@example.com
2nd Parent Cell Phone

Area CodePhone Number
Medical Insurance Company*
Please enter None if you don't have insurance at this time.
Med Ins. Policy #*
Please enter None if you don't have insurance at this time.
Emergency Contact (other than parent)*

First NameLast Name
Emergency Contact Phone #*

Area CodePhone Number
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken.
Please list/explain any allergies we should know about:
1st Student's Date of last tetanus shot:*

MonthDayYear
Date
2nd Student's Date of last tetanus shot:

MonthDayYear
Date
3rd Student's Date of last tetanus shot:

MonthDayYear
Date
For your information, we expect each student to conform to these rules of conduct:

No possession or use of alcohol, drugs, or tobacco
No fighting, weapons, fireworks, lighters, or explosives
No cussing
No offensive or immodest clothing
No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
Participation with the group is expected
Respect property
Respect one another, staff, and adult leaders
Respect and comply with event schedules
My student(s) has/have my permission to attend youth activities sponsored by Foundation Church at Lakewood (hereinafter the “Church”) from January 1, 2024 to December 31, 2024.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

I/We have read the rules of conduct, given the above evaluation of my child’s health to the best of my knowledge, and hereby grant permission for my child to participate in church-sponsored youth/children’s activities. I agree to abide by, and ensure my child abides by, the stated personal limitations and code of conduct.

I/We are aware that photos or video may be taken of Foundation Youth and Children Ministry participants during events, activities, and classes by Foundation staff, professional photographers, or volunteers. I/We also understand that my child is not required to have his/her picture taken. I waive the right to see or approve any publications that contain legal photographs of my child. I give Foundation UMC permission to use photographs or video that include my child in any and all media products for promotion, art, advertising, editorial, or other purpose. This may include but is not limited to newsletters, both print and email, posters, brochures, ads, postcards, and web pages.

BY SUBMITTING THIS FORM I AGREE TO THE AFOREMENTIONED TERMS AND STIPULATIONS.
Should be Empty: