Microsoft word - medical release jan 1- dec 31 2013.doc

Medical Release & Permission Form
Effective dates: January 1, 2013 through December 31, 2013

Please print in ink

Name: ___________________________________________________ Medical Insurance Company Policy # Mother’s name Physician ________________________________________Office Phone __________________________________ Medical Information
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.
Check the following areas of concern for this student. If necessary, add another page with details:
1. For your child’s safety and our knowledge, is your student a⎯
2. Does your child have allergies to⎯ 3. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following: 6. Is your child taking any prescribed medications? If so, please list: I also do hereby authorize the adult chaperones representing Brentwood Oaks Church of Christ to administer any of the non- prescription medications checked below: _____ Acetaminophen (Tylenol) for headache or pain _____ Ibuprofen (Advil) for headache or other pain _____ Dramamine (for nausea or car sickness) _____ Pepto-Bismol (for upset stomach or diarrhea) _____ Benadryl (for allergic reactions ONLY – will NOT be given as a sleep aid) Medical Release & Permission Form
For your information, we expect each student to conform to these rules of conduct

No possession or use of alcohol, drugs, or tobacco No fighting, weapons, fireworks, lighters, or explosives No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters Participation with the group is expected Respect one another, staff, and adult leaders
Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group
activities. I agree to abide by the stated personal limitations and code of conduct. Student signature: ______________________________________________________ Date: __________________ Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller-skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the church youth minister prior to that event. Has my permission to attend all youth activities Sponsored by BRENTWOOD OAKS CHURCH OF CHRIST(“hereinafter the Church”) from January 1, 2013 to NAME OF ORGANIZATION DATE This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Brentwood Oaks Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its ministers, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. Parent/Guardian Signature: ________________________________________________ Date: __________________


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