MEDICAL & LIABILITY RELEASE FORM

First Presbyterian Church

40 Church Street / Asheville, NC 28801

www.fpcasheville.org (this form is available online)

FAX (828-253-3192)

 

This form (1) gives your permission for your child to ride in church transportation and (2) gives the group leaders authorization to secure medical aid for your child should it be necessary.

 

I, ­­­__________________________________, consent to allow ___________________________________

                      (Parent or guardian)                                                                              (Minor’s name)

 

to be transported from and to First Presbyterian Church in church transportation for various youth activities. I hereby authorize any hospital, clinic, physician, doctor, nurse or technician to furnish my child, named above, any medical care treatment necessary as a result of injuries sustained or other emergency medical treatment as the circumstances require while being transported from and back to the church and while at the place of destination. I hereby authorize a representative of the First Presbyterian Church to retain or acquire said medical care and treatment in my behalf if I can not be reached by telephone or there is not time or opportunity to make such a telephone call. I agree not to hold such a person responsible for any damages arising from the giving of such consent.

 

Signature of parent(s) or legal guardian(s) _____________________________ Date __________

 

Address ________________________________________________________

City ____________________ State               _________ Zip ______________________

 

Home Phone ______________ Bus. Phone _______________________ Cell phone _______________

 

Please list any health problems or allergies:

 

 

 

Please list any and all medications (name, dose, prescribing doctor)

 

 

 

CHILD’S SOCIAL SECURITY #: ______________________ DATE OF BIRTH ______________

MEDICAL INSURANCE CO: ________________________    POLICY # _________________

REGULAR DOCTOR: _________________ PHONE: __________________

EMERGENCY CONTACT: _____________ PHONE: __________________