Medical release and consent

1100 Carter Creek Parkway, Bryan, Texas 77802-1129 MEDICAL RELEASE AND CONSENT
Name _______________________________________________________________________ Address _____________________________________________ Phone ___________________ Parent _____________________ Home ______________ Work _____________ Cell ________ Parent _____________________ Home ______________ Work _____________ Cell ________ Medical Insurance Carrier _________________________________ Policy/Group #__________ Subscriber Name _________________________ ID # _______________ Date of birth _______ Prescription Carrier ________________________ RxBin ________________ RxGroup ______ Subscriber Name _________________________ ID # _______________ Date of birth _______ Name ______________________ Home _____________ Work ______________ Cell _______
Medical History
Physician ___________________________________________ Phone ______________ Dentist _____________________________________________ Phone ______________ Hospital ____________________________________________ Phone ______________ Chronic Illnesses _________________________________________________________ Allergies ________________________________________________________________ Medications _____________________________________________________________ Important Information _____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ In the event of an emergency where medical treatment is required, I give my permission to the church staff or youth sponsor present of the First Presbyterian Church of Bryan, Texas, to obtain the services of a licensed physician for the person named on this form. Please attempt to notify me immediately concerning any emergency. ______________________________________ Public\Staff\Office FPC\Forms\Medical Release and Consent.doc

1100 Carter Creek Parkway, Bryan, Texas 77802-1129 ===================================================================== My youth may be given any the following at normal adult dosage, if necessary (check all that apply):  Diphenhydramine (Benadryl)  Rolaids/Tums I DO HEREBY RELEASE AND CONSENT to the participation in any youth event/activity and am aware that activities may include participation in sporting/recreation/construction events. In addition, I give my permission for any videos or photographs taken to be used in any FPC-Bryan publication or the FPC-Bryan web site. I DO HEREBY CERTIFY that I am physically fit and capable of participating. I DO HEREBY SPECIFICALLY RELEASE, waive, discharge, and covenant not to sue FPC-Bryan, its staff, volunteers, agents, and governing bodies, for any action or causes of action, including, but not limited to, personal injury, property damage, or wrongful death, which may exist or which may hereafter arise during and following the participation in any youth event/activity. IN CASE OF EMERGENCY, I do hereby give permission to the physician selected by the group leader to hospitalize and secure proper treatment for the registered person as named on this form. _____________________________________ *Note. If participant is under 18 years of age, this form must be co-signed by parent or legal guardian. _____________________________________ Public\Staff\Office FPC\Forms\Medical Release and Consent.doc


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