hpumcyouth.org

Medical Release Form

Participant's Last Name:*
Participant's First Name:*
Participant's Middle Name:
Date of Birth:*	(Format: mm/dd/yyyy)
Participant SSN:
SSN is requested to expidite care in an emergency
Home Address:*
Home Phone:
Parent/Guardian #1 Name*
Parent/Guardian #2 Name:*
Parent #1 Cell:*
Parent #2 Cell:*
Other Phone:
Current Medical Problems:*
Past Medical History:*
Medication Allergies:*
Prescription Medications:*
Last Tetanus:*	(Format: mm/dd/yyyy)
Current CDC guidlines: Booster every 10 years. Significant Laceration: Booster within 5 years
Physician Name & Phone:*
Insurance Company:*
Policy/Group Number:*
Policy Holder:*
Insured Date of Birth:*	(Format: mm/dd/yyyy)
Insured SSN:
Emergency Contact:*
Emergency Contact Phone:*
Parent or Guardian*	By Checking this box I confirm that I am the above stated parent or guardian for this child.
Permission/Info Accuracy*	By checking this box I give my child permission to participate in Highland Park United Methodist Church actvities. The information I have put on this form is accurate and it is my responsibility to keep this form current.
Over the Counter Medicaiton*	By checking this box I allow my youth to reieve over the counter medications if the need arises.
Consent for Treatment*	By checking this box I give permission to HPUMC youth staff or volunteers to authorize medical treatment for my child if I am unable to be reached. I release this person from any liability that arises from the consent given for my child.
Release*	By checking this box I release HPUMC, the Staff, volunteers and agencies they work with of any liability in the event of accident or injury due to my childs participation with HPUMC Youth Ministry.
	To prevent spam, please answer the following question. What is the sum of two and three?*