Microsoft word - medical release form 13-14

Providence Presbyterian Church 2013-2014
Permission, Release, and Authorization for Medical Treatment Form

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Student Information

Guardian & Student’s primary e-mails to use for communication:

Health Insurance Information
In the case of injury or illness requiring medical attention while your child is participating in a PYF event or
activity, your health insurance will be billed. Do you have health insurance?

Health History Information

Pre-existing or present medical conditions:
Name and dosage of any medications that must be taken:
Permission to Administer Medications

I give permission for the below indicated medications to be administered to my youth at my youth’s request or
as deemed necessary by adult leaders. Check all that apply.
Continued on Reverse
Permission, Release, & Authorization for Medical Treatment
September 1, 2013– August 31, 2014
Emergency Contact Person (parent/primary guardian)
Full Name:
Alternate Contact Person (relative/family friend/secondary guardian)
Full Name:

Providence Youth Fellowship Transportation Policy (October, 1999, p.8)
The Providence Presbyterian Church Child Protection Policy states the following:
Transportation It is recommended that children be transported in groups rather than alone. A child’s parent or guardian may give permission for an unaccompanied adult to drive a single child, or children, in a church-sponsored activity. Parental permission should be obtained in writing. This policy is not intended to prohibit staff of adult volunteers from offering a ride home to children in emergency situations. The adult leader shall make a reasonable attempt to contact parents prior to providing the ride. No young person under the age of 18 will be allowed to drive other youth on the church program trips.
Parental Permission, Release of Liability, and Authorization for Medical Treatment
permission for my youth to participate in any and all of Providence Presbyterian Youth Fellowship events and
activities from September 1, 2013 through August 31, 2014. I understand that youth may not drive any other youth
on any PYF events. I give my permission for my youth to ride with an unaccompanied PYF leader, should the
situation arise, during any off-site PYF events or activities.
I understand that in the event that medical intervention is needed, every attempt will be made to immediately contact me or the alternate contact person listed on this form. In the event that I cannot be reached in an emergency during the activity dates of September 1, 2013 through August 31, 2014, I hereby give my permission to the physician, dentist, or hospital selected by the activity leader to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my youth as deemed necessary. I understand that my insurance coverage for my youth will be used in the event that medical intervention is I understand that the Providence Presbyterian Church PYF and its leaders will take all reasonable safety precautions while youth are in authorized locations during the events and activities of the PYF program. I understand the risk of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Providence Presbyterian Church or the Providence Youth Fellowship, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by my youth.
Photo Release

I hereby give permission for images of my child, taken during Providence Presbyterian Church activities through
photo and digital camera, to be used in publications promoting Providence Presbyterian Church including albums on
the Providence Presbyterian Church website and the Providence Presbyterian Church newsletter. I understand that
my child’s name will not be used without parent/guardian permission.
Permission, Release, & Authorization for Medical Treatment
September 1, 2013– August 31, 2014


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