UCC MSM Medical Release Form

UCC Medical Release Form
Student Information:
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Grade*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student's Cell #
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Address (if different than student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Home #
Parent/Guardian Cell #*
Parent/Guardian E-mail*
Parent/Guardian #2 Name

First NameLast Name
Address (if different than student or Parent/Guardian #1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Home #
Parent/Guardian #2 Cell #
Parent/Guardian #2 E-mail
example@example.com
Person other than parent to contact in case of emergency:
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Insurance/Medical Information
Medical Insurance Company*
Policy #*
Group # (if applicable)
Policy Holder's Name*

First NameMiddle InitialLast Name
Student's Doctor*
Doctor's Phone #*
Date of Last Tetanus Shot

MonthDayYear
Date
Current Medications
Does the student have any allergies, chronic illness, special dietary needs, or medical conditions? If yes, please describe.
As Parent and/or Guardian of the named student, my son/daughter has my permission to be treated and/or cared for by a designated representative of University Christian Church. Said person may delegate emergency treatment as deemed medically necessary. I understand that all reasonable safety precautions will be taken at all times by University Christian Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold University Christian Church, its leaders, employees, and volunteer staff, et al., liable for damages, losses, diseases, or injuries incurred by the subject of this form.

By signing this form, I authorize University Christian Church to use pictures and/or video footage of my child for its social media, website, or other promotional materials.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

UCC Medical Release Form

Insurance/Medical Information