EmailMe Form - MEDICAL RELEASE AND PERMISSION FORM

Today's Date *

MM / DD / YYYY

Minor's Full Name *

First Last

Birthdate *

MM / DD / YYYY

Minor’s Social Security *

Tee Shirt Size
(some service trips and other opportunities have a tee shirt available)

Small

Medium

Large

Extra Large

MINOR’S MEDICAL HISTORY

Please list allergies (if any)

Current Medications

Date of Last Tetanus Shot: *

MM / DD / YYYY

Other Relevant Medical/Social Concerns:

MEDICAL INSURANCE INFORMATION

Insurance Company *

Phone

### - ### - ####

Policy/Group# *

Regular Physicians Name:

Primary Insured (parent/guardian): *

First Last

PARENT/LEGAL GUARDIAN EMERGENCY CONTACT INFORMATION

Name *

First Last

Relationship to Minor *

Email Address *

Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Main Phone *

### - ### - ####

Cell Phone

### - ### - ####

Work Phone

### - ### - ####

Place of Employment *

Emergency Contact Person (other than parent/legal guardian) *

First Last

Emergency Contact Person (other than parent/legal guardian)
Main Phone *

### - ### - ####

Emergency Contact Person (other than parent/legal guardian)
Cell Phone

### - ### - ####

Emergency Contact Person (other than parent/legal guardian)
Work Phone

### - ### - ####

PARENT/LEGAL GUARDIAN EMERGENCY CONTACT INFORMATION

As the custodial parent or legal guardian of the minor named above. I am aware of the involvement and participation of this minor in activities at and excursions with Montview Boulevard Presbyterian Church groups, staff, and adult chaperones. I request and authorize the staff and adult chaperones of MBPC to exercise temporary custody and care of this, my minor child while on church-related events.
During such time as my child is in the care of the staff and/or adult chaperones, and in the event that my child shall need medical treatment or care, including, but not limited to emergency surgery, hospitalization, or other emergency or non-emergency medical care, I hereby authorize and consent to such medical treatment and care that may be deemed necessary for my child, at my expense.
I shall be responsible for any and all costs or expenses of providing such care and treatment for my child, and shall reimburse, indemnify, and hold harmless Montview Boulevard Presbyterian Church, its staff and adult chaperones from same.
I further understand that it is solely my responsibility to provide the church with an updated MEDICAL RELEASE AND PERMISSION FORM if any changes occur in the information provided above. I understand that this form will remain on file at the church to be used for all events in which my child participates. I understand that Montview Boulevard Presbyterian Church is committed to providing a safe environment for my child/youth and executes background checks and provides safety training as part of the church Safe Sanctuary Policy for all staff and chaperones. Montview staff and adult chaperones will make every effort to contact parents/guardians in the event that an accident or injury occurs involving my child. I understand that any information that is shared with Montview staff and leaders will be held in confidence with the goal of ensuring my child’s safety and wellbeing while in Montview’s care.

BEFORE ME, THE UNDERSIGNED AUTHORITY PERSONALLY APPEARED:

This form needs to be notarized. This can be accomplished in 2 ways:
1. Print the form and take it to be notarized
2. Submit form and send an email to Angela Cummins at angela@montview.org to make arrangements to have your signature notarized at the church office.

Name *

First Last

Sworn to and subscribed

MM / DD / YYYY

Notary Signature

First Last

Montview Boulevard Presbyterian Church is committed to the safety of all those participating in church activities. All staff and volunteer leaders are screened through background checks and trained in safety procedures as outlined in the church’s Safe Sanctuary Policy.