2020 Medical Release Form - Minor
Student Information
Full Name
*
First Name
Middle Name
Last Name
Birthdate
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Month
-
Day
Year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
Please Select
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Connecticut
Delaware
District of Columbia
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Maine
Maryland
Massachusetts
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New York
North Carolina
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Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
I live with my...
*
parents (both mom & dad)
mom
dad
mom sometimes, dad sometimes
other
Home Phone Number
Student Cell Number
Student E-mail
Parent/Guardian Information
Preferred Email Address
*
Father's Name
*
First Name
Last Name
What phone numbers does your father regularly use?
*
Cell
Work
Father's Cell
*
Father's Work
*
Mother's Name
*
First Name
Last Name
What phone numbers does your mother regularly use?
*
Cell
Work
Mother's Cell
*
Mother's Work
*
Guardian's Name
*
First Name
Last Name
What phone numbers does your guardian regularly use?
*
Cell
Work
Guardian's Cell
*
Guardian's Work
*
Emergency Contact Information
used if parent/guardian is unreachable
Emergency Contact Name
*
First Name
Last Name
Relationship
*
e.g. neighbor, friend, aunt, grandfather, etc.
What phone numbers does your emergency contact regularly use?
*
Home
Cell
Work
Home Number
*
Work Number
*
Cell Number
*
Medical Information
Insurance Carrier
*
Policy Number
*
Doctor's Name
First Name
Last Name
Doctor's Phone Number
Health Issues
*
if none, enter "N/A"
Known Allergies
*
if none, enter "N/A"
Medications (name/dosage/purpose)
*
if none, enter "N/A"
Last Tetanus Booster
*
-
Month
-
Day
Year
Date
Additional Instructions
Agreement
*
(I, We) hereby give permission for my child to participate in the student activities of Neighborhood Bible Church. (I, We) the undersigned parent(s)/person having legal custody/legal guardianship of the above-mentioned student, a minor, do hereby authorize Neighborhood Bible Church as agent for the hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority of power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnoses, treatment or hospital care which a physician, meeting the requirements of this authorization, may in the exercise of her/his best judgment, deem advisable. The authorization is given pursuant to the provisions of Section 56.11 of the Civil Code of California. (I, We) hereby authorize any hospital which has provided treatment to the above-named minor(s) pursuant to the provision of Section 56.11 of the Civil Code of Californian to surrender physical custody of such minor to (my, our) above named agent upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California. These authorizations shall remain effective until December 31, 2020 unless sooner revoked in writing delivered to said agent(s).
Signature
Clear
Date
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Month
-
Day
Year
Date
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