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Medical Release Form
For what area of ministry are you completing this form?
*
Children's Ministry (Pre-K - grade 5)
Middle School Ministry (grades 6-8)
High School Ministry (grades 9-12)
Student's Name
*
First
Last
Student's Date of Birth
*
MM slash DD slash YYYY
Student's Grade
*
Mother/Guardian's Name
*
First
Last
Cell Phone Number
*
Email Address
Father/Guardian's Name
*
First
Last
Cell Phone Number
*
Email Address
With whom does student live?
*
Address Where Student Lives
*
Street Address
Address Line 2
City
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American Samoa
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Vermont
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Armed Forces Americas
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State
ZIP Code
Alternative Phone Number (e.g. Home)
Emergency Contact Name (other than parent/guardian named above)
*
First
Last
Emergency Contact Phone Number
*
Emergency Contact Relationship to Student
*
Name of Healthcare Provider and/or Preferred Hospital
*
Physician's Name
First
Last
Healthcare Provider Address
Street Address
Address Line 2
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Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
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Iowa
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Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Health History
Drug allergies
Hay fever
Diabetes
Insect sting allergies
Food allergies
Heart condition
Chronic asthma
Physical handicap
Epilepsy/nervous disorders
Other (list in special notes below)
Name and dosage of any medication student takes on a regular basis
Please list any special notes
By submitting this form, you confirm that you are the parent or guardian of the student for whom this form is completed, or are the student and are over age 18. By submitting this form, you are also agreeing to the following statements: In the unlikely event that I or my appointed emergency contact cannot be reached in an emergency while my student is with Bridges Community Church, I hereby give my permission to the physician selected by the Bridges Community Church supervisors to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my student as deemed necessary. I understand that all billings for services rendered will be sent to me as the parent/legal guardian and that I am responsible for the complete payment. In the unlikely event that my student is injured while participating in activities on or off the campus of Bridges Community Church or in route to such activities, my student and I relinquish all rights to recover damages for any and all injuries sustained by my student during or in route to activities. I acknowledge that if my student has to return home early for discipline violations, it will be at the parent/guardian’s expense. I also understand that photos and videos may be taken of my student while at Bridges Community Church events, which may be used by Bridges Community Church for future promotional purposes.
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