Medical Release and Permission Form

Silverwood

Name _____________________________________________ Birthday ______________ Age ________

Address __________________________________________________City ________________________

State _________________ Zip ___________________ Phone # _________________________________

In case of emergency notify: _____________________________________________________________

Father’s work # _____________________________ Mother’s work # ____________________________

Father’s cell # ______________________________ Mother’s cell # ______________________________

Family Physician __________________________________________ Phone (____) ________________

Insurance Carrier __________________________________  Policy No. __________________________

Immunizations:    ________ Tetanus    ________ Polio Booster    ________ Measles   _________ Mumps

Drug allergies _________________________________________________________________________

Past Medical History

(check giving appropriate information)

______ Asthma   ______ Sinusitis    ______ Bronchitis    ______Kidney Trouble    ______ Heart Trouble

______Diabetes    ______ Dizziness    ______ Stomach Upset    ______ Hay Fever

Allergies: Food: _______________________________________________________________________

Penicillin or other drug (name): ___________________________________________________________

Insect stings/bites: ___________________________ Poison sumac, oak, or ivy: ____________________

Previous operations or serious illness: ______________________________________________________

Any current medications you are taking (list): ________________________________________________

Special diet (name): ____________________________________________________________________

Childhood diseases:  ____Chickenpox  ____Measles  ____ Mumps  ____ Whooping Cough  ____ Other

Parents Permission

As a parent/legal guardian, I give permission for the child named above to participate in the Richland 1^st Church of the Nazarene NazKids Silverwood Trip.

I understand all reasonable safety precautions will be taken at all times by Richland 1^st Church of the Nazarene and Naz Kids Ministries and its agents during the events and activities. 

I authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency.

I understand the possibility of unforeseen hazards and know the inherent possibility of risk.

I agree not to hold Richland 1^st Church of the Nazarene and Naz Kids Ministries, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

_____________________________________________                      ______________________

Parent or Legal Guardian  / Phone                                                                             Date