Sanction by parent or guardian for consent to a different for hospitalization, surgery, or particular medical procedures on the absence of parent or guardian.

(Please print or type all necessitated info.)

Child’s name: _________________________________ Date of Birth: ________________

HEALTH HISTORY
Medical troubles: Diabetes _ Epilepsy _ allergic reactions _ What type? _____________

Additional _ Explain: _____________________________________

Tetanus (date of final injection): _______________________________________________

Is your child nether medical treatment at present? Yes _ No_
If yes, explicate:

Is your child taking any medicaments at present? Yes _ No_
If yes, what type? _____________________________________________________

Child’s doctor.: ________________________________ Phone# __________________

INSURANCE (please furnish a photocopy of insurance card if conceivable)
Name of Insured: __________________________________________________________

Medical Carrier: ____________________________ Group or ID#___________________

PARENT OR GUARDIAN LEGALLY RESPONSIBLE FOR CHILD
Distinguish: __________________________________________________________________

Home phone #: _________________________ Cell phone #: ______________________

I do herewith release the suitable staff of River Cities Community Church (RCCC) from any liability or
responsibility arising out of any chance event wherein stated participant and his/her material possession is damaged, and for any medical, infirmary, physician, or pharmaceutic expenses arising out of any stated fortuity. I additional grant the appropriate staff of RCCC the authority to empower medical treatment for participant at whatever time medical treatment is conceived essential in the judgment of stated staff for whatever illness, disease, or physical injury.

Signature _____________________________ Date ________________

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