Spiro FBC Medical Information and Release Form

Medical Release Form

Student First Name

Student Last Name

Student Age

Student Gender

Email Address

Address

City

State

Zip

Mobile Number

Emergency Contact Name

Emergency Contact Ph#

Family Physician

Family Physician Ph#

Are you being treated for an illness at this time?

Please Explain

Do you require a special diet?

Please Explain

Do you require physical accomodations?

Please Explain

Do you have (or ever had) any of the following? Seizures, Diabetes, Asthma, Heart Murmur, Kidney Disease, Allergies, or something else?

Please Explain

Are you currently taking ANY medications or carry an Epinephrine injector?

Please list them here.

Is there pertinent information we need to know in the case of an emergency?

Please Explain

I hereby authorize Spiro FBC and it's representatives to act in my place in the event of a medical emergency and to make medical decisions up to and including initiating emergency medical treatments, first aid, calling an ambulance and transporting my child to an emergency department.

I Agree

I, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities at Spiro FBC Youth Ministries, and any other supervised activities customarily associated with its youth group, including youth rallies and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events. I hereby release Spiro FBC and all of it’s staff/volunteers from any and all legal liabilities for any injuries or damages incurred as a result of participation in these activities. If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing.

I Agree

Parent/Guardian E-Signature