Children's Ministry  Medical Release Form

Student's Name *
Student's Name
Birthdate *
Birthdate
Student's Health History
Allergies and Health Conditions
Please explain each of the areas checked and Please list all medications currently being taken
Parent Information
Mother's Name *
Mother's Name
Mother's Address
Mother's Address
Mother's Cell Phone
Mother's Cell Phone
Father's Name *
Father's Name
Father's Address
Father's Address
Father's Cell Phone
Father's Cell Phone
Emergency Contact
Emergency Contact
If parent's can not be reached
Emergency Contact Cell Phone
Emergency Contact Cell Phone
Insurance
Primary Doctor's Name
Primary Doctor's Name
Primary Doctor's Number
Primary Doctor's Number
Medical Release & Consent 1
Digital Signature
Medical Release For acknowledgment and agreement *
By selecting this button, I acknowledge that I have read and agree to the Medical and liability release form.