The Community Church of Sebastopol, UCC 

P O Box 579   Sebastopol   CA 95473      

(707) 823-2484    www.uccseb.org

Emergency Medical Release Form:

Name_______________________________________________________ Gender________ Age_______ DOB______________

Address_____________________________________________________________City _____________________Zip________

School___________________________________________________________________________________ Grade_________

Parent1/Guardian Name___________________________________________________________________________________

Home Phone_________________________Work Phone________________________Cell Phone_________________________

Parent2/Guardian Name___________________________________________________________________________________

Address (if different)___________________________________________________ City _____________________Zip ________

Home Phone _________________________Work Phone_______________________ Cell Phone_________________________

Other Emergency Contact:______________________________________________ Relationship to youth___________________

Home Phone _________________________Work Phone_______________________ Cell Phone_                  

Family Physician ____________________________________________________ Phone _______________________________

Dentist ____________________________________________________________ Phone ______________________________

Eye Doctor _________________________________________________________ Phone_______________________________

Date of most recent tetanus shot/booster________________________________ Glasses or contacts worn? _________________

Allergies to medications? Please list__________________________________________________________________________

Any other Allergies? (type, description of symptoms, etc) ___________________________________________________________

_________________________________________________________________________________________________________________________

Is emergency medication required for this allergy? _______________________________________________________________

Does your child have any condition or limitation the leaders should know about to assure his/her well being at youth events and activities?

Please

Explain_________________________________________________________________________________________________

Has your child had any major illness at any time which may affect his/her ability to participate in any activity?

Please

Explain_________________________________________________________________________________________________

Medical History    Has your child been subject to any of the following?  (Please check all that apply)

May the medical supervisor administer any of the following to your child?

I give my permission for my child to receive the above medications as indicated by the “Yes” column.  Before treatment is provided for any other illness or injury, parental contact or physician advice will be sought.

IN CASE OF MEDICAL EMERGENCY, I give permission to the physician selected by the Youth Leaders to secure proper treatment for, hospital, and order injection, anesthesia or surgery for my child named.  (Every effort will be made to contact parent or guardian.)

IMPORTANT:  I will notify the Youth Leaders if my child is exposed to any communicable disease during the two weeks prior to attending any function.

I, the undersigned parent/guardian of the named minor, do hereby authorize The Community Church as agent for the above named to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff at any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.  It is understood that this authorization is given in advance of a specific diagnosis, treatment or hospital are being required but is given to provide authority and power on the part of my aforesaid agent to give specific consent to any and all such diagnosis, exercise of his best judgment may deem advisable.  I hereby authorize any hospital, which has provided treatment to the above named minor pursuant to the health and safety provision for any and all States in the United States of America and to surrender physical custody of such minor to my above named agent upon the completion of treatment.  These authorizations shall remain effective until September 15, 2008, unless revoked sooner in writing and delivered to said agents.  A photocopy of this authorization shall have the same force and effect as the original.

Parent/Guardian Signature__________________________________________________ Today’s Date_____________________

 Printed Name: _________________________________________________________________

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Community Church of Sebastopol, UCC

1000 Gravenstein Hwy. North   T   P.O. Box 579

Sebastopol, CA  95473

(707) 823-2484    T  fax (707) 823-9597

Click here for directions              email: office@uccseb.org

This page was last updated on: 06/25/2008