Fox Chapel Presbyterian Church
412-963-8243
Medical Release Form
June 1, 2009 to May 31, 2010
PERSONAL INFORMATION:
Name ____________________________________________Home
Phone ________________
Last First Middle Initial
Home Address _______________________________________________________________
Street
City Zip
Birth Date _______________
Sex: _____ Female _____ Male
Parent(s)/Guardian, if participant is under the age
of 18:
Father’s Name __________________________________
Address ________________________________________________________________
Street
City Zip
Phone #’s:
Home ____________ Work ____________ Cell
____________
Mother’s Name __________________________________
Address (if same leave
blank)
______________________________________________________________________
Street
City Zip
Phone #’s:
Home ____________ Work ____________ Cell
____________
EMERGENCY: In case of emergency, notify (if
parent(s)/guardian is not available):
Name ____________________________________________ Home Phone
_______________
Relationship __________________
Work Phone ____________ Cell Phone ______________
Address
_____________________________________________________________________
Street City Zip
HEALTH HISTORY: All participants MUST complete the following.
Please
check the allergies the participant may have:
Allergies Type of reaction
q Medicines ___________________________________________________
q Insect stings ___________________________________________________
q Hay Fever ___________________________________________________
q Asthma ___________________________________________________
q Foods ___________________________________________________
q Others (specify) ___________________________________________________
Any
specific activities to be encouraged limited or avoided:
Current Medication:
Name Dosage When Taken
______________________ _______________ __________________________________
______________________ _______________ __________________________________
______________________ _______________ __________________________________
Family Physician:
Name
______________________________________Phone
Number ____________________
Insurance Information:
Name of Insurance Company
____________________________________________________
Policy Number _______________________________ ID Number
_______________________
Parent(s)/Guardian Please read and
sign below:
The health
history is correct as far as I know. I
know and understand that unanticipated events might arise. I give permission for
_____________________________________ to participate in activities except as
noted. I also give permission to
authorize personnel to carry out such emergency diagnostic and therapeutic
procedures as may be necessary for myself or my child and also permit such
treatment procedures to be carried out at, any by the local hospital(s) for myself
or my child in the event of an emergency.
I understand that any medical expenses will be billed directly to me or
my insurance company.
I also give
the supervising adult permission to administer minor first-aid procedures.
_______________________________________________ Date ______________________
Participant (if 18 or older) / Parent
or Guardian Signature
q
Please DO NOT
use photographs of this participant for church publicity including brochures
and website.
Please Note:
I understand this medical information will be kept on file this year and
will accompany the participant on all off site activities. If any of the above information changes, it
is my responsibility to notify Fox Chapel Presbyterian Church, in writing, of
the changes.
_______________________________________________ Date ______________________
Participant (if 18 or older) / Parent
or Guardian Signature