Youth Medical Form

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Medical and Liability Release Form RELEASE OF ALL CLAIMS
This form needs to be completed and signed by a parent or guardian. The annual medical and liability release form is designed to provide information in the event of an emergency, permission to seek medical treatment, and parental consent of participation.
Youth Information:
Name of Youth (First, Middle Initial, Last):^*
Youth Birthday^*
Anticipated High School Graduation Year
Parent/Guardian Information:
Mom/Guardian First Name
Mom/Guardian Last Name
Mom/Guardian Email
Mom Mobile Phone
Dad/Guardian First Name
Dad/Guardian Last Name
Dad/Guardian E-mail
Dad Mobile Phone
Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Emergency Contacts:
Please list information for two people who could be contacted in case of emergency if the parent/guardian cannot be reached (relatives, close friends). These people may provide information regarding where the parent/guardian might be reached, or they might be asked to give advice/permission for medical care. Please notify individuals that their names have been given for this purpose.
Emergency contact one name^*
Emergency contact one relation to youth^*
Emergency contact one mobile number
Emergency contact one address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Emergency contact two name^*
Emergency contact two relation to youth^*
Emergency contact two mobile number
Emergency contact two address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Doctor and Insurance Information
Name of Primary Care Physician
Primary Physician Phone
Primary Physician Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Name of Insurance Company
Insurance Policy Number
Name of subscriber

General Health Information and History
Has/does the student... (check all that apply)
Had any recent injury, illness, or infectious disease?

Have chronic or recurring illness or condition?

Ever been hospitalized?

Ever had head injury?

Ever been knocked unconscious?

Wear glasses or contacts?

Ever been dizzy or passed out during or after exercise?

Ever had seizures?

Ever had high blood pressure?

Ever been diagnosed with a heart murmur?

Ever had back problems?

Ever had problems with joints (i.e. knee ankles)?

Use an orthodontic appliance?

Have diabetes?

Have asthma?

Had mononucleosis in the past 12 months?

Have frequent stomach aches or indigestion?

Have problems with sleep walking?

Ever had an eating disorder?

Have any allergies to medication?

Have any food allergies?

Have any other allergies (i.e. insect bites, hay fever, animal dander, etc.)?

Please explain any checked boxes above.
Date of Last Tetanus Immunization
Other Health Information

Medication Info
My child takes NO medications on a routine basis.

My child may be given pain relievers (i.e. Tylenol, Motrin, etc.) as needed.

My child takes medications as follows:

Med #1
Med #1 Dosage
Med #1 Time for Dosage
Med #1 Reason for taking
Med #2
Med #2 Dosage
Med #2 Time for Dosage
Med #2 Reason for taking
Med #3
Med #3 Dosage
Med #3 Time for dosage
Med #3 Reason for taking

MEDICAL RELEASE AUTHORIZATION BY PARENTS/GUARDIANS:
After failed attempts to contact us (me), we (I) authorize the responsible adult representing St. Paul Lutheran Church, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home to do medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by St. Paul Lutheran Church.
We (I), the undersigned, for ourselves, our heirs, executors, and administrators, understand and agree that in consideration of the participation of my child in youth ministry events and activities, hereby agree to release discharge, and hold harmless St. Paul Lutheran Church , its staff, officers, and agents, from all liability and loss (including court costs and attorney fees), resulting from any property damage, personal injury and bodily injury, including death, to my child, which is caused or claimed to be caused, in whole or in part, by the negligent acts or omissions of St. Paul Lutheran Church, its staff, officers, and agents.
Consent is also given to the photographing of our (my) child and the recording of his/her voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. Further consent is given to the reproduction and/or authorization by St. Paul Lutheran Church to reproduce and use said photographs and recordings of our (my) child’s voice, for use in all domestic and foreign markets. It is understood that the term “photograph” as used herein encompasses both still photographs and motion picture footage.
SIGNATURE OF PARENT/GUARDIAN (.jpg):
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SIGNATURE OF PARENT/GUARDIAN (.jpg):
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Today's Date:

Medical and Liability Release Form RELEASE OF ALL CLAIMS

Youth Information:

Parent/Guardian Information:

Emergency Contacts:

Doctor and Insurance Information

General Health Information and History

MEDICAL RELEASE AUTHORIZATION BY PARENTS/GUARDIANS:

Youth Quick Links