Youth Medical Release FormPlease enable JavaScript in your browser to complete this form. – Step 1 of 4Family InformationAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeStudent #1Student Name *FirstLastLayoutStudent EmailBirthdayGrade7th8th9th10th11th12thStudent CellGenderMaleFemalePrefer Not to AnswerSchoolMedicalAllergiesInsect bite/stingDrugFoodOtherCheck all that applyAllergy DetailsOther ConditionsHeart ConditionDiabetesAsthmaEpilepsyHay FeverFrequent ColdsFrequent Upset StomachPhysical HandicapGlasses/ContactsHearing AidsSwimming RestrictsActivity RestrictionsOtherCheck all that applyPlease provide further details for all selected conditions above.Please list over-the-counter medications that may be administered to the student.Date of last tetanus shot/boosterDo you need to register another child? *NoYesStudent #2Student NameFirstLastLayoutStudent EmailBirthdayGrade7th8th9th10th11th12thStudent CellGenderMaleFemalePrefer Not to AnswerSchoolMedicalAllergiesInsect bite/stingDrugFoodOtherCheck all that applyAllergy DetailsOther ConditionsHeart ConditionDiabetesAsthmaEpilepsyHay FeverFrequent ColdsFrequent Upset StomachPhysical HandicapGlasses/ContactsHearing AidsSwimming RestrictsActivity RestrictionsOtherCheck all that applyPlease provide further details for all selected conditions above.Please list over-the-counter medications that may be administered to the student.Date of last tetanus shot/boosterDo you need to register another child?NoYesStudent #3Student NameFirstLastLayoutStudent EmailBirthdayGrade7th8th9th10th11th12thStudent CellGenderMaleFemalePrefer Not to AnswerSchoolMedicalAllergiesInsect bite/stingDrugFoodOtherCheck all that applyAllergy Details *Other ConditionsHeart ConditionDiabetesAsthmaEpilepsyHay FeverFrequent ColdsFrequent Upset StomachPhysical HandicapGlasses/ContactsHearing AidsSwimming RestrictsActivity RestrictionsOtherCheck all that applyPlease provide further details for all selected conditions above.Please list over-the-counter medications that may be administered to the student.Date of last tetanus shot/boosterDo you need to register another child?NoYesStudent #4Student NameFirstLastLayoutStudent EmailBirthdayGrade7th8th9th10th11th12thStudent CellGenderMaleFemalePrefer Not to AnswerSchoolMedicalAllergiesInsect bite/stingDrugFoodOtherCheck all that applyAllergy DetailsOther ConditionsHeart ConditionDiabetesAsthmaEpilepsyHay FeverFrequent ColdsFrequent Upset StomachPhysical HandicapGlasses/ContactsHearing AidsSwimming RestrictsActivity RestrictionsOtherCheck all that applyPlease provide further details for all selected conditions above.Please list over-the-counter medications that may be administered to the student.Date of last tetanus shot/boosterNextGuardian 1Name *FirstLastLayoutCell Number *Work NumberHome NumberGuardian 2NameFirstLastLayout (copy)Cell NumberWork NumberHome NumberWith whom does the student live?Emergency ContactIn case of an emergency, please provide the name and number for of someone other than a parent/guardian that can be contacted.LayoutName *FirstLastPhone *Relation to student *NextInsurance InformationLayoutPhysicianPhoneLayout (copy)DentistPhone Is the student covered by insurance?YesNoPrimary InsuranceSubscriber's NameFirstLastLayoutSubscribers Date of BirthLast 4 Digits of Social Security NumberNextGUARDIAN RESPONSIBILITYIt is the parent’s responsibility to find out all details of youth programs, trip activities, including all Sunday and Wednesday events. Parents are responsible for knowing all details of any off-campus trips, including trip location, departure and return times. Parents are asked to read youth newsletters, regularly check youth information bulletin boards in the church, emails, church website, or call for specific details. I accept these terms.Guardian InitialDateIn the event of an emergency where I am unable to provide information, I hereby give permission to the medical professional selected by the church leadership to secure proper treatment, including but not limited to: medical evaluation, medical injection, anesthesia, surgery, and hospitalization for my child as deemed necessary. I accept these terms.Guardian InitialDateMEDIAIn the event of an emergency where I am unable to provide information, I hereby give permission to the medical professional selected by the church leadership to secure proper treatment, including but not limited to: medical evaluation, medical injection, anesthesia, surgery, and hospitalization for my child as deemed necessary. I accept these terms. (copy)Guardian InitialDateLIABILITYI have read and understand this form. I certify the above named student is my child (or under my legal guardianship) and resides with me. I give my consent for him/her to attend and participate in activities, functions, and trips sponsored by First Presbyterian Church, Georgetown. I assume all transportation costs, should it be necessary for my child to return home due to medical or disciplinary actions. I accept these terms.Guardian InitialDateI do hereby release, forever discharge, and agree to hold harmless First Presbyterian Church, Georgetown, its staff, youth leaders, chaperones and volunteers thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred while participating in any activity or trip. I assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein by my child. I understand by my signature that this form is both a binding medical and liability release. I accept these terms.Clear SignatureDateSubmit
