SunHouse Medical Release Form

282854_10151419385477489_432904430_n.jpg
Student's Name *
Student's Name
Birthdate *
Birthdate
Student's Health History
Allergies
Major Conditions
Please check all that apply
Please explain each of the areas checked
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
Digital Signature
Media Release
Media Consent - I hereby give my full consent to La Jolla Presbyterian Church (LJPC) and it's ministries to record (video, photograph, audio recording or other) my and my child's participation in any programs or events associated with LJPC. Further, I hereby transfer and assign to LJPC the exclusive rights to use and to authorize others to use said images, video, photography, audio recordings or other, for promotional and educational use or resource sale in the future. I understand that my image, voice or video recording may be used, but my name or personal information will never be shared publicly without additional, separate consent.