Permission/Medical Release Form

Childs Full Name_________________________________________________________

Childs Full Name_________________________________________________________
Childs Full Name_________________________________________________________
Childs Full Name_________________________________________________________
Insurance Carrier _________________________________________________________
Policy Number__________________________ Group Number_____________________
Insureds Name___________________________________________________________
In Case of Emergency Contact (Name): _______________________________________
Emergency Number: ______________________________________________________
Allergies:________________________________________________________________
_______________________________________________________________________
Special Instructions:_______________________________________________________
_______________________________________________________________________
Medical Release: I give permission for hospital or medical center staff to administer any necessary
treatment immediately to my child, should he/she be sick or injured during ______________________ at
______________________________on the date of ____________________________. I do not hold Life
Church and its respective volunteers and staff responsible for any injury during as a result of my childs
participation in this event.
Parent/Guardian Signature__________________________________________________