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Children's Medical Release | 2022 on Saturday, December 31, 2022 @ 8:00 AM

Please complete all fields on this form, including the signature box at the bottom.
Did you put the child whom this medical release is associated with in the "First Name" and "Last Name" boxes above? If not, please do so now. 
*Child's Birthdate:
*Current Grade/Age Group:
The following fields relate to the Parents or Legal Guardian:
*Parent/Guardian 1:
*Full Name 1:
*Cell Phone 1:
Home or Work Phone 1:
*Email 1:
*Parent/Guardian 2:
*Full Name 2:
*Cell Phone 2:
Home or Work Phone 2:
*Email 2:
If parents or guardians are unavailable, who should we contact?:
*Emergency Contact Full Name:
*Relation to family:
*Phone #:
Please provide information about insurance (N/A if you do not have insurance) and any medical concerns we should be aware of:
*Primary Medical Insurance Company:
*Policy #:
*Full Name of Policy Holder:
*Child's Primary Care Physician:
*Physician's Phone #:
*Name of Dentist/Orthodontist:
*Dental Phone #:
Food allergies and medical plan if exposed:
Chronic illness or medical conditions:
List Any Activity Restrictions:
*tetanus shot:
This health information is correct so far as I know, and I expressly consent to the participant's involvement in all activities and events for 2022.
I hereby release First Presbyterian Church and its staff and sponsors from responsibility and liability for any injury or illness that my child may sustain during church-sponsored activities. In the event of an emergency, I hereby authorize an adult leader of the activity, as agent for me, to consent to any examination or treatment by physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible.
By typing my first and last name in this box I am signifying that I am the parent or guardian for the child listed above and have the authority to enter into this agreement on their behalf.:
*First & Last Name:
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