Permission Form and Medical Release

Student's Name____________________________________Age___________Grade__________

Address__________________________________City_____________State________

Student's Email________________________________________

Parent's Email_________________________________________

Home Telephone: (      )___________________________________

SS #:__________________________________________________

Parent/ Guardian Names: __________________________________

Day Phone: (      )_________________________________________

Cell Phone: (      )_________________________________________

Insurance Carrier:_________________________________________

Policy#__________________________________________________

Group No.:_______________________________

Subscriber's Name/ S.S.#_________________________________________

Primary Care Physician:_________________________Phone:(     )____________

Medications being taken by student:_________________________________________________________________________________

Allergies:________________________________________________________________________________

Other Important Medical infromation:______________________________________________________________________________

Emergency Contact (Other than Parent): ________________________________________________________________________________________

Relationship to student:_________________________________

Phone (     ):____________________________________________

I have filled out the above information accurately to the best of my knowldege, I understand that I need to contact the church if this information changes. I authorize the Youth Leaders to seek and/or give emergency medical treatment to my youth if needed, and understand that I will be contacted immediately if medical treatment is needed.

Parent Signature___________________________________Date:_______________