Insurance Release Form

Your name *

Email address *

Phone number

Address

Birthdate

Grade

School

Father/Guardian's Name

Father/Guardian's Cell

Mother/Guardian's Name

Mother/Guardian's Cell

Emergency Contact

Name, Phone Number, & Relationship to Youth

Insurance Information

Health Insurance Company

Policy Holder

Policy Number

Doctor's Name

Doctor's Phone Number

Medical Information

Allergies

Food, Medications, insect bites/stings, other..

Medications Currently Taking

All prescription medications must be in original bottles, labeled with patient name, doctors name, time and dosage to be taken. OTC medications must be in original container.

My child may be given Tylonel or Advil if needed

Yes

Parent/Guardian Signature

IN CASE OF EMERGENCY: If I am unable to be reached, I give permission to the Smyser Christian Church, by its representatives to hospitalize, secure treatment for, and to order anesthesia or surgery for my child named above. I further agree to be responsible for any and all bills incurred for such treatment.

I, herby, give full authority to the representatives of Smyser to use his/her discretion in determining if such medical treatment is necessary, and I release the Smyser Christian Church (i.e. representative, leadership, and congregation) from any and all responsibility for the results of that determination.

I further release Smyser Christian Church and its representatives from any responsibility other than supervision and care of my child.

Signature

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