Episcopal Diocese of Iowa Emergency Information, Medical Release, and Media and Photo Release
For the year January 1, 2026 through December 31, 2026
Participant Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your age?
Date of Birth
-
Month
-
Day
Year
Date
What is your gender identity?
Parent/Guardian Name(s)
First Name
Last Name
Parent/Guardian Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Insurance Information
Insurance Company
Policy #
Physician Information
Physician Name
Phone Number
Dentist Information
Dentist Name
Phone Number
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I, the undersigned, have legal custody of the Participant, a minor.
I understand that there are inherent risks involved in any ministry or athletic event, and I 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 my child(ren) is injured and requires the attention of a doctor, I 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 agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I 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 affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the participant named above. I also agree to bring my child home at my own expense should he/she become ill or if deemed necessary by the Church retreat leaders.
About the Participant
Are there any life circumstances (death, divorce, change in family circumstances, change of school, insomnia, homesickness, etc) or health conditions of which the adult staff should be aware? Does your child have a physical, behavioral, or emotional disability, a 504 plan or an IEP?
Yes
No
Please explain.
How does your child do away from home? Do they have trouble sleeping? Are there things we can do to help?
Medical History
This information will be kept confidential and shared only with adult team members as necessary.Please attach additional sheets of paper as necessary with the following information.
Are you currently taking any medication?
Yes
No
Please list each medication and dosage.
Do you have any allergies (medication, pollen, insect bites, other)?
Yes
No
Not Sure
Please list them.
If there is an exposure, what should be done?
Please list any dietary restrictions or food allergies.
Does participant suffer from, or has ever experienced, or is being treated currently for anyof the following:
Asthma
Epilepsy/seizure disorder
Diabetes
Physical Handicap
Frequent upset stomach
Heart issues
Other
Please give additional information
Date of last tetanus shot?
Does participant wear:
Glasses
Contacts
Media & Photo
The participant agrees to grant the Church permission to record via photographs and/or video their participation at this youth event and further agrees that any or all material recorded may be used, in any form, as part of any future production made by the Church and that such use shall be without payment of fees, royalties, special credit, or other compensation. This form is valid until such time that it is revoked by the undersigned. Parent/Guardian signature is needed.
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