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Parental Consent & Medical Authorization
Please fill out this form or update any information.
Student's First Name
Student's Last Name
Insurance Company
Insurance Card Number
Policy Number
Parent's Email
Parent's Phone Number
Emergency Contact Person | First Name
Last Name
Emergency Contact Phone Number
Is your child presently being treated for an injury or sickness or taking any form of medication for any reason?
Yes
No
If yes, please provide specifics.
Is your child allergic to any medication?
Yes
No
If yes, please provide specifics.
Date of last tetanus shot:
Does your child have (or has ever had) any of the following: (Check if yes; explain on the space provided).
Seizure Disorders
Asthma
Heart Murmur
Diabetes
Hay Fever
Kidney Disease
Fainting Spells
None of the above
If yes, please explain.
Does your child have any allergies other than medical?
Yes
No
If yes, please explain.
Parental Consent: I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in ALL of the regularly scheduled activities of Refuge Student Ministries at Bethel Assembly of God, Chambersburg, PA 17201, from January 1, 2017—December 31, 2017, including: trips, camp outs, swimming, boating, hiking, sporting events, and any other activities customarily associated with a church’s Youth Ministry. Furthermore, I certify that my child is physically fit and adequately trained to participate in such events (except as noted). I understand that I will be notified in case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that the Bethel Assembly of God will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I agree to notify the Church in the event of any changes from above which would restrict my child’s participation in any normal children/youth activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child. Parent/Guardian Signature (Typed name will act as signature)
Date of Signature
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