MEDICAL RELEASE FORM CHRIST LUTHERAN MINISTRIES

September 2005 through September 2006

 

            Name of Youth _____________________________________________

 

            Address ___________________________________________________

 

            Phone _____________________________________________________

 

            Date of Birth ________ Age_______ Church Affiliation___________________

 

In the event my child _______________________ must be given emergency medical treatment while participating in an activity sponsored by Christ Lutheran Church, I hereby authorize Christ Lutheran Church and it’s agents to act on my behalf in arranging treatment in case I cannot be reached by telephone or the nature of my child’s condition requires immediate medical attention.  I release Christ Lutheran Church and it’s agents from any liability in securing medical treatment for my child. The authorization is given pursuant to the provisions of Section 25.9 of the civil code of California and shall remain effective until revoked IN WRITING and delivered to said agent (s).  I have read and understand this statement and have completed to the best of my ability the requested information below.

 

1.      Drug Allergies  __________________________________________________

 

2.      Most recent Tetanus vaccination  ___________________________________

 

3.      Other medical conditions  _________________________________________

 

Insurance Company ____________________ Policy Number _______________

 

In the event of any emergency and parents or guardian cannot be reached, please contact:

 

Name ___________________      Relationship ___________   Phone ___________

 

Name ___________________      Relationship ___________  Phone ___________

 

The above listed minor child has my (our) permission to attend activities sponsored by Christ Lutheran Ministries.

 

Date ______ Father’s Signature ______________________    Phone # ____________

 

Date ______ Mother’s Signature ______________________   Phone # ____________

 

Date ______ Guardian’s Signature ____________________   Phone # ____________

 

 

 

 

Christ Lutheran Youth Ministries, 760 Victoria St., Costa Mesa, CA, 92627    (949)631-1611