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Medical Release Form
Medical Release Form 2023 to 2024 - Up to four children per form.
Address
City, State, and Zip Code
Email Address
Mother's First Name
Mother's Last Name
Primary Phone
Secondary Phone
Father's First Name
Father's Last Name
Primary Phone
Secondary Phone
Emergency Contact
Emergency Phone Contact
Relationship to Child
Physician
Dentist
Insurance Company
Phone
Policy Number
Name of Insured
Although it is our sincere desire to provide a safe environment for our children, we also recognize that accidents can, and sometimes do, happen. If such a situation should occur, our first response will be to contact you, the parent, unless it is a life-threatening injury where it would be wise to seek immediate medical attention. One purpose of this form is to allow us to obtain first aid or emergency care for your child if we are unable to contact you. Since trips/activities are arranged for the benefit of those participating, it is understood that Maywood Evangelical Free Church, its employees, and volunteers will execute caution, good judgment, and care but cannot be responsible in case of accident, injury, and loss or damage of property in connection with any trip/activity, and the undersigned will save them harmless from all such claims. You also agree to allow your child(ren) to be transported to and from Maywood events with authorized Maywood drivers and grant permission for them to attend activities that may occur offsite. I agree to release Maywood Evangelical Free Church, its volunteers and employees, from and against any and all liability, loss, damages, claims or actions to the maximum extent permissible by law, arising out of such transportation. The undersigned further agrees to admonish the child participating in the program to exercise care, to be well-behaved and in all things obedient to and under the direction and control of those leaders in charge.
Today's date
Child #1
Child First and Last Name
Gender
Girl
Boy
Date of Birth
Grade Level
Physical disabilities or limitations
Allergies / other concerns
Date of last tetanus shot
Child #2
Child First and Last Name
Gender
Girl
Boy
Date of Birth
Grade Level
Physical disabilities or limitations
Allergies / other concerns
Date of last tetanus shot
Child #3
Child First and Last Name
Gender
Girl
Boy
Date of Birth
Grade Level
Physical disabilities or limitations
Allergies / other concerns
Date of last tetanus shot
Child #4
Child First and Last Name
Gender
Girl
Boy
Date of Birth
Grade Level
Physical disabilities or limitations
Allergies / other concerns
Date of last tetanus shot
Enter Code
Submit
Becoming a People to Reach People for Christ
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Maywood Free Church