Urban Plunge 11

Urban Plunge 11 Medical Release
CHILD INFORMATION:
Name of Child or Adult Participant*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Participant's Cell Phone Number*

Area CodePhone Number
Participant's E-mail*
example@example.com
Name of School
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above, or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. If I, as a parent or guardian, am unable to be contacted by phone, I do hereby give permission for Zachary Pennell or agents of Good Samaritan Community Covenant Church to seek and secure any needed medical attention or treatment for the child name above, or me, if I am a participant.

I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment and I agree to pay for the medical treatment. Furthermore, unless stated otherwise in the area of Medical History, I give the adult leaders permission to dispense over-the-counter medications (i.e. ibuprofen, acetaminophen, antacids, topical ointments, etc.) to my child if needed.
MEDICAL INFORMATION
Physician Name

First NameLast Name
Phone Number

Area CodePhone Number
Medical History/ Concerns*
Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.) If none, put *N/A*
Health Insurance
Insurance Company*
Policy Number*
Policy Phone Number*

Area CodePhone Number

Parent's Name*

First NameLast Name
Parent's Signature*

Clear
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

Urban Plunge 11 Medical Release

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

First Aid and Emergency Medical Treatment

MEDICAL INFORMATION

Health Insurance