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:

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

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Religion
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Name of Parent/Guardian

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

First NameLast Name
Doctor's Phone Number

Area CodePhone Number
Current Medications
Known Allergies
Medical Conditions
Date of Last Tetanus

MonthDayYear
Date
Name of person other than parent in case of emergency:

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Should be Empty: