Advent Lutheran Church, Snohomish, WA.
Medical Release Form for Aug. 1st, 2005 to July 31st, 2006
I understand that in the event of an emergency, or if any medical or surgical care becomes necessary for ______________________________________, every attempt will be made to contact me. If I am unavailable, I grant those in charge of this event permission to authorize medical attention as recommended by a licensed physician. We agree to pay all medical costs involved in such an emergency treatment. We release and discharge the Evangelical Lutheran Church in America and/or its representatives involved in this event from any liability in exercising this permission.
If any of this information should change during the year, please call to update this form.
Legal Parent or Guardian (please print): ______________________________________________
Signature: ____________________________________________ Date: ___________________
Address: ______________________________________________________________________
Daytime phone: _________________________ Evening Phone: _________________________
Cell phone(s): __________________________________________________________________
Emergency contact (other than parent or guardian): _______________________________________
Daytime phone: _________________________ Evening Phone: _________________________
Relationship to young person: _____________________________________________________
Physician name: _________________________________ Phone: _________________________
Insurance company: ____________________________ Policy number: ____________________
MEDICAL INFORMATION Date of last tetanus shot: ____________________________
Allergies, including drug allergies: __________________________________________________
______________________________________________________________________________
Current medication with instructions for use and other medical information:
The above information is confidential and will not be released except in case of emergency.