Children & Youth Medical Release Form

Please fill out this form for your child/youth. Please fill out a separate form for EACH of your children.

I hereby give permission for my child to go on all announced, scheduled activities with Community Presbyterian Church Youth Fellowship.
Parent's Name
I hereby release Community Presbyterian Church, its pastors, and any leader or other participating ministry involved in this event from any liability regarding any accident, injury or disease sustained or contracted by my child while participating in any children’s activity. Should any problem arise which requires medical attention and the emergency contact(s) listed below cannot be reached, I also hereby agree to the performance of such treatment, anesthetics and operations that in the opinion of the attending physician is deemed necessary. I further agree to hold harmless Community Presbyterian Church, its pastors, or any leader from any medical, hospital or dental bills incurred as a result of any injury, accident, or disease sustained or contracted by my child while on a CPC activity.
Parent's Name
Youth Information
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Grade
Gender
Youth's Physician
Physician's Phone Physician's Phone - ### - ### ####
Primary Insurance Company
Policy #
Please upload a picture of your child's insurance card.

Attach Files
Please List Your Child's Alergies, Medical Conditions and/or Medications
Date of Last Tetanus Shot
Swimming Ability
Parent/Guardian Information
Name Name First Last
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please list any additional contacts with phone numbers in case of emergency.
Parent/Guardiatn draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Children & Youth Medical Release Form

Children & Youth Medical Release Form

I hereby give permission for my child to go on all announced, scheduled activities with Community Presbyterian Church Youth Fellowship.

Youth Information

Parent/Guardian Information