Annual Medical Release/Permission Form

Resurrection United Methodist Church of Hastings requires a medical release and liability waiver for each child/student participating in activities at church or other facilities, such as camp, retreats, etc. This form must be updated annually and covers all student activities for one year.

Parent/Guardian Information

Parent/Guardian Name

Primary Phone

Secondary Phone

May we send you text messages?

Yes No

This address will receive a confirmation email

Additional Parent/Guardian Name

Additional Phone

Additional Email

Primary Address

Is this also the primary address of the student?

Yes No

Emergency Contact

Use the parent/guardian information listed above for emergency contact?

Yes Yes, plus additional contact below No, use contact below

Relationship to Student

Emergency Contact Person

Emergency Contact Phone

Emergency Contact Email

This address will receive a confirmation email

List Other Authorized Emergency Contact Information Here

Student Information

Student Name

Student Date of Birth

Current Grade Level

Student eMail

Student Phone

Student Medical Info

Allergies (check all that apply): Bee Stings Milk Peanut Poison Ivy Other

Known Diseases or Conditions (check all that apply): Asthma Diabetes Epilepsy Heart Condition Immunosuppression Kidney Lung Condition Other

Difficulties (check all that apply): Back Injuries Bowel Habits Colds Headaches Menstrual Neck Injuries Sore Throats Other

Any other allergies, diseases/conditions or difficulties?

Date of last Tetanus shot?

Is he/she taking medication(s)?

Yes No

Over-the-counter Medications
By selecting any of the listed over-the-counter medications below, I authorize a representative of Resurrection United Methodist Church of Hastings and/or medical professionals to administer said medication in accordance with label instructions if requested by my child.

Medications: Advil Benadryl Dramamine Imodium AD Pepto-Bismol Tums Tylenol Prescription Meds sent with student from above list

Does your child have a history of seizures?

Yes No

Physician/Clinic Name

Physician/Clinic Phone

Liability Waiver/Medical Release

I/we, the undersigned parent(s)/legal guardian(s) of the above minor(s), do hereby release and agree to not hold Resurrection United Methodist Church of Hastings and/or any related member, employee, sponsor or agent from any liability, injury, damages, loss, accidents, delay, or irregularity related to the listed minor’s planned participation in Resurrection United Methodist Church of Hastings and/or related camps/retreats/activities. I/we also hereby give consent for emergency medical care prescribed by a duly licensed doctor of medicine or doctor of dentistry or at a hospital licensed by the State of Minnesota. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. This release covers all rights and actions of every kind, nature, and description, which the minor and his/her parent(s)/legal guardian(s) ever had, now has, or but for the release, may have.

Please enter your initials and today's date below. Your initials represent your authorized signature for consent purposes on this form, which will remain valid for one year from today's date.

Parent/Guardian Initials

Today's Date

Annual Medical Release/Permission Form

Description

Please Fix the Following