Medical Release Form

Participant's Last Name:*
Participant's First Name:*
Participant's Middle Name:
Date of Birth:*
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 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 Medication*	By checking this box I allow my child to receive 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, and volunteers of any liability in the event of accident or injury due to my childs participation with an HPUMC event.
Covenant Anytime you participate with HPUMC Students you are representing the Christian Faith and HPUMC. We want to make sure that all are conducting themselves in a manner that is respectful, filled with common sense and loving. We expect that all participants respect themselves and all leaders and other participants with their words and actions. We do not allow any illegal activity, including but not limited to: drinking, tobacco use, vandilism, stealing. We want everyone to have fun with us but we expect the rules to be followed and anytime a student is in violation of these rules they may be sent home at the cost of the parents.
Covenant Acceptance*	By checking this box I have review this information and reviewed it with my child. I understand that at anytime my child's behavior or actions violate the covenant and guidelines of HPUMC Students they will be sent home at my expense
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Medical Release Form

Covenant