Medical Form (Trips) — ferncreekKIDS

THIS MEDICAL RELEASE FORM IS FOR OVERNIGHT EVENTS LED BY FERN CREEK KIDS.

Participant's Name

First Name

Last Name

Participant's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant's Date of Birth

YYYY

Emergency Contact's Phone Number

(###)

###

####

Emergency Contact's Email Address

Medical conditions and medicine provided:

Health Insurance Information

Any Food or Drug Allergies?

Any additional information that we need to know so that we can best care for the participant?

I hereby grant permission to secure such emergency medical care as may require. I give permission to Fern Creek Christian Church to provide emergency treatment for my child in the event of illness or an injury. In the event of serious injury or illness, I understand that every attempt will be made to contact the legal guardian listed below at the phone number listed. I understand that emergency medical treatment will not be delayed while trying to make this contact. I give permission to Fern Creek Christian Church to use media that is produced from this event that includes my child for promotional use. Also, I understand that when Fern Creek Christian Church makes overnight accommodations, that the church assimilates children based on their biological sex. Please acknowledge this statement by typing your name (must be 18 years or older).