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Microsoft word - student medical release form 2010-11.doc

Pathways Community Church STUDENT Medical Release and Liability Form

I (We) acknowledge that my child’s participation in the activities of Pathways Community Church is voluntary and
may require involvement in traveling and physical exertion. My child has permission to attend all church
sponsored activities as listed in calendars or on PCC website, including but not limited to the following:
cookouts, boating, water skiing, surfing, wind surfing, paddle boarding, tubing, swimming in lakes & oceans,
hiking, biking, rollerblading, skating, ice-skating, paintball, broomball, basketball, soccer, volleyball, softball,
football, ultimate frisbee, camping. In consideration of the activity or event my minor child is participating in,
I hereby represent and warrant that my minor child is fully, physically, and medically capable of partaking
in same and that accidents, injuries, death and/or damages caused by other individuals may occur.
It is my
consent on behalf of my minor child to acknowledge and assume such possibility and I/we hereby release and
forever discharge Pathways Community Church, its officers, agents, employees, and representatives, from all
claims, damages, injuries, medical treatment expenses, medical transportation expenses and causes of action that
may arise from the event or activity.
I (We), the parent(s) or legal guardian, do hereby authorize any one or more members of Pathways Community
Church, in whose care the minor has been entrusted, as agents for myself in my absence or incapacitation to consent
to any x-ray examination and anesthetic, medical, surgical, or dental diagnosis or treatment and medical care which
is deemed advisable by and is to be rendered under the general or special supervision of any physician, physician’s
assistant, licensed practical nurse, EMT or surgeon licensed under the provisions of the Medical Practice Act on the
medical staff of any hospital or out patient clinic, whether or not such diagnosis or treatment is rendered at the office
of said physician or medical staff or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical
and/or dental services rendered, including emergency medical transportation, to the aforementioned child pursuant
to this authorization.
It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being
required but is given to provide authority and power on the part of the aforesaid agents to give specific consent to
any and all such diagnosis, treatment or hospital care which aforementioned physician in the exercise of his or her
best judgement may deem advisable.
I hereby authorize any hospital or physician which has provided treatment to the above-named minor to surrender
physical custody of such minor to the above-named agents upon the completion of treatment.
These authorizations shall remain effective until August 31, 2011.
Copies of this form, duly executed, should be in the possession of the named minor; at least one adult named in the
document and present at the event; and the parent or guardian executing the Medical Authorization. A duly
executed copy of this form shall have the same force and effect as the original.
Parent(s)/Legal Guardian Signature______________________________________________Date______________
STATE OF FLORIDA
COUNTY OF PINELLAS
BE IT KNOWN, that on the _____day of _____________, __________, before me, the undersigned notary in
and for the State of Florida, duly commissioned and sworn, dwelling in the county of Pinellas, personally came
and appeared _________________________________________, to me ( ) personally known or ( ) who
produced valid identification, and being the same person described in and who executed and acknowledged the
within medical authorization and release to be his/her act and deed.
Health Information Form
Please Print in Ink Name________________________________________________________Birthday_____/_____/_____ Parent/ Guardian______________________________________________________________________ Phone (H)_____________________Phone(W)_______________________Phone(C)________________ Address_____________________________________________________________________________ City______________________________________State__________________________Zip__________ Second Parent/or Alternate Emergency Contact______________________________________________ Phone (H) ________________________Phone(W)_____________________Phone(C)______________ Medical Insurance Carrier _______________________________________________________________ Policy #_____________________________________ Group #_________________________________ Carrier Address_______________________________________________________________________ Name of insured person ________________________________________________________________ Insured person’s place of employment_____________________________________________________ Name of Family Physician ___________________________________ Phone _____________________ Name of Dentist/Orthodontist___________________________________Phone ____________________ Health History (Check/Give Approximate Dates) Allergies (Dates Not Needed)
____Frequent Ear Infections ____Diabetes ____Bleeding Disorders
____Heart Defect/Disease ____Asthma ____Mononucleosis ____Ivy Poisoning, etc _____Insect Stings ____Seizures ____ADD/ADHD ____Downs Syndrome ____Other _______________________________ Chronic/recurring illness/medical conditions including mental illness (depression, anxiety, etc.)
____________________________________________________________________________________
Dietary Restrictions____________________________________________________________________

Current Medications (list all prescriptions, OTC and herbal)
Attach Separately Medication name / Dosage / Reason for Taking

Blood Type (if known)_____ All immunizations current? Yes____ No _____ Date Last Tetanus_________
Describe your student’s swimming ability: Beg___________ Inter__________ Advanced __________
Any other information you feel the leaders should know in advance about your student?
____________________________________________________________________________________
____________________________________________________________________________________

Initial__________ I give my permission to the staff to administer Tylenol/Acetaminophen,
Ibuprofen, Benadryl, Diphenhydramine or over the counter antacids, as needed.
Initial________ My child may sleep on a top bunk.
For your information, these are the rules of conduct expected from each student:

Respect one another, staff and adult leaders No alcohol, dugs, tobacco permitted No lighter permitted No fighting, weapons, fireworks, explosives No students permitted to drive for events Respect property No offensive or immodest clothing No boys in girls’ sleeping quarters, visa versa
Parent(s)/Guardian Signature______________________________________Date_________________
Student’s Signature______________________________________________Date_________________

Source: http://www.pathwayscc.net/ersm_downloads/Medical_Release_Form_2010_11.pdf

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