D’WAVE Youth Ministries
Medical Release Form
June 2008 – May 2009
Please
complete a separate form for each student and attach a copy of your
insurance card.
Name of student________________________________
Age________ Birth date_____/_____/_____ Gender: M F
Social
Security #_________________ Name of Parent/Guardian___________________________________________
Address_________________________________________________
City__________________________ State_____
Home
Telephone (________) _____________________ Work Telephone (________)
_____________________
Alternate
Emergency Contact: ______________________________________________________________________
Address____________________________________________________
City_______________________ State_____
Home Telephone
(________) _____________________ Work Telephone (________) _____________________
Insurance
protection is the responsibility of the student’s family.
Insurance
Carrier_________________________________________________________________________________
Group
Number______________________________ Policy Number___________________________
Please list
all allergies: ____________________________________________________________________________
Most recent
Tetanus Toxoid Inoculation: _____________________________________________________________
Medication(s)
presently using:
Name Purpose Dosage
Taken When?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
I give
permission for my student to take the following non-prescription medications as
needed:___________________
_______________________________________________________________________________________________
Please
indicate dates and types of serious operations and illnesses: _________________________________________
_______________________________________________________________________________________________
Is this
student restricted from any activities (i.e., hiking, swimming)
________________________________________
_______________________________________________________________________________________________
Is there
anyone who is legally restricted from seeing this student? __________________________________________
To the best
of my knowledge, the information on this form is accurate and complete. In case
of injury or sudden illness, I hereby give authority for any hospital or doctor
to render immediate emergency aid for my child as might be required at the time
for his/her health and safety. It is understood that the expense of this
service will be accepted by the legal parent/guardian of this student.
Signature of
Parent/Guardian_______________________________________________ Date____________________