VPC | Medical Information/Release Form

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Medical Information/Release Form

Children's Ministries

Release and Hold Harmless Agreement & Medical Information Form

(One form per child please)

Child's Information

Child's Name

Gender

MaleFemale

Date of Birth

Grade (2011-12 school year)

Complete Address

Parent's Information

Parent's Name(s)

Guardian's Name
(if different)

Home Telephone

Mother's Cell Phone

Father's Cell Phone

Mother's Occupation

Mother's Work Phone

Father's Occupation

Father's Work Phone

Child's Medical Information

Known allergies or problems (enter "none" if appropriate)

Hospitalization Insurance Co

Policy Number

Physician

Phone Number

Nearest Relative/Friend
(Please list the name of nearest relative or friend to be contacted
in case of emergency if parents cannot be reached)

Alternate Name

Alternate Home Phome

Alternate Cell Phone

Relationship

Acknowledgement
By clicking the "Submit" button below, I (the parent named below) grant permission for my child (named below) to participate fully in activities or trips sponsored by Vienna Presbyterian Church.
I understand that this acknowledgment carries with it:

1. An authorization of any of the adult leaders to obtain necessary medical attention and/or
treatment for my son/daughter.

2. I knowingly release, absolve, indemnify, and hold harmless Vienna Presbyterian Church
from all claims that might result from any injury or death of any minor.

3. Should medical help be needed, I agree to pay either directly or through my own health
and accident insurance policy all medical or hospital costs.

Parent's Name

Child's Name

Final Review
• Please review all information you have entered on this form.
• Use the Browser's Back button to cancel this submission.

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Medical Information/Release Form

Children's Ministries