PARENTAL PERMISSION AND MEDICAL RELEASE FORM

This form is to remain in the possession of Adult Advisor at all times.

 

Chews United Methodist Church

319 Black Horse Pike, Glendora, New Jersey 08029

856-939-1007

 

Name:___________________________________                         Date of Birth:______________________

 

 

Parent/Guardian:__________________________                         Home Phone:______________________

 

Address:_________________________________                         Cell Phone:________________________

 

_________________________________________

 

Emergency Contact:_______________________                         Relationship:_______________________

 

Address:_________________________________                        Home Phone:______________________

 

_________________________________________                         Cell Phone:________________________

 

¯Medical Information¯

Dietary Restrictions:_______________________                         Allergies:__________________________

 

Current Medications:_______________________                         Date of Last Tetanus Shot:___________

 

Daily Treatment/Medications:________________                         Activity Restrictions:________________

 

_________________________________________                         __________________________________

 

Family Physician:__________________________                         Phone:____________________________

 

Family Dentist:____________________________                         Phone:____________________________

 

¯Copy of Insurance Card must be attached to this form¯

 

Do you carry family medical/hospital insurance?                           Yes _________     No__________

 

Carrier:___________________________________                         Policy Number:_____________________

 

This health history is correct as far as I know, and the person herein described has permission to engage in all activities except as noted.

 

AUTHORIZATION FOR TREATMENT

 

I HEREBY GIVE PERMISSION to the medical personnel selected by the Adult Leaders of the Chews United Methodist Church to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my child.

 

I HEREBY GIVE PERMISSION FOR MY CHILD, ____________________________________________

 

TO ATTEND ____________________________________________________________________________________

 

Signature of Parent/Guardian:__________________________________         Date:____________________

 

Witness-Signature of Adult Advisor______________________________          Date:__________________