Emergency Medical Consent Form 2018/2019

Emergency Medical Consent Form 2018/2019
Please fill out one form per child.
I give my child, (named below) permission to participate in Sunday School trips and events hosted/sponsored by the East Woodstock Congregational Church from September 1, 2018 to August 31, 2019.
In case of emergancy, my child may be treated at the nearest medical facility:

Yes No
If No, please list alternative:
Full Name of Child

First Name Last Name
Date of Birth

- Month - Day Year
Date
Age
Religion

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
Cell Phone Number

- Area Code Phone Number
Name of Parent/Guardian

First Name Last Name
Employer of Parent/Guardian
Health Insurance Company
Policy Number
Family Doctor

First Name Last Name
Doctor's Phone Number

- Area Code Phone Number
Current Medications
Known Allergies
Medical Conditions
Date of Last Tetanus

- Month - Day Year
Date
Name of person other than parent in case of emergency:

First Name Last Name
Phone Number

- Area Code Phone Number
Relationship to Child
Signature of Parent/Guardian

Clear
Date

- Month - Day Year
Date
Should be Empty:

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