VBS Medical Information & Release Form

Medical Information and Release

Seaside United Methodist Church 1300 Seaside Rd., SW Sunset Beach, NC 28468 For Vacation Bible School, June 23-27, 2014

Child's Name
First Last

Enter the name of child.
Level in School*
Age*
Name of School
Date of Birth
MM
DD
YYYY
Name of Parent/Guardian*
First Last
Add a second Parent/Guardian?*
- Yes
- No
Name of additional Parent/Guardian
First Last
Person Completing this form:
- Parent/Guardian above
- Second Parent/Guardian listed
- Other
Name of Person Completing Form*
First Last
Relationship to Child*
Address where child lives*
Street Address Address Line 2 City State ZIP Code
Home Phone
Parent/Guardian Work Phone
Parent/Guardian Cell Phone
Second Parent/Guardian Cell Phone
Alternate Contact in Case of Emergency*
Alternate Contact Phone #*
Relationship to Child*
Family Doctor*
Phone Number*
Family Dentist
Phone Number
Does the child have health insurance?*
- Yes
- No
Health Insurance Company*
Policy Number*
Insurance Company Phone Number*
List all known allergies.*
If none, please enter none.
Medical History-brief description of child's medical history and any know condition*
List all medications and frequency of use.*
If none, please enter none.
Dietary or physical restrictions.*
If none, please enter none.
In the event I am unable to be reached at the numbers above, I hereby authorize emergency medical treatment, surgery, or dental care to be given to my son/daughter, as considered advisable or necessary in the judgment of an emergency medical professional or attending physician. I shall be liable and agree to pay all costs and expenses incurred in connection with any medical services need for my youth.
Consent*
- I agree to the above consent statement
Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Medical Information and Release

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