Children's Ministry Family Information/Medical Release

Children's Ministry Family Information/Medical Release

This information is VERY IMPORTANT. Please fill out all information -- One Form per family
Head of Household*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Spouse (if applicable)

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Children Information

Please fill in information for all children in your home 6th grade and under
1st Child's Full Name*

First NameMiddle NameLast Name
1A) Child's Birth Date *

MonthDayYear
1B) Child's Grade*
Grade in school next fall
1C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
1D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
1E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
2nd Child's Full Name

First NameMiddle NameLast Name
2A) Child's Birth Date

MonthDayYear
2B) Child's Grade
Grade in school next fall
2C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
2D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
2E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
3rd Child's Full Name

First NameMiddle NameLast Name
3A) Child's Birth Date

MonthDayYear
3B) Child's Grade
Grade in school next fall
3C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
3D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
3E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
4th Child's Full Name

First NameMiddle NameLast Name
4A) Child's Birth Date

MonthDayYear
4B) Child's Grade
Grade in school next fall
4C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
4D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
4E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)
5th Child's Full Name

First NameMiddle NameLast Name
5A) Child's Birth Date

MonthDayYear
5B) Child's Grade
Grade in school next fall
5C) If your child has any Allergies, please list here:
(Nuts, Food dye, Dairy, etc.)
5D) If your child has any Special Needs, please list here:
(Autism, Sensory Processing disorder, Seizure disorders, etc.)
5E) If your child is taking any special medications, please list here:
(Albuterol inhaler, Ritalin, etc.)

Medical Release

I give my children permission to attend Children’s Ministry events. I realize that this event is being offered by the Downtown Church of Christ and will not hold them responsible for accidents. I give the sponsors at events the right to correct and discipline our children for behavior we deem inappropriate and in order to promote a good atmosphere for all involved. I, do hereby authorize any full-time staff with the Downtown Church of Christ as agents for the undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold harmless any physician, hospital, or other medical center for rendering of such services.
Do you agree to these terms?*

I have read and acknowledged all above information, permissions, and give my consent.

Insurance Information
Insurance Company Name*
Policy Number*
Policy Holder's Name*

First NameMiddle NameLast Name
Place of Employment*
Employment Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Any medical information that needs to be known?
Enter the message as it's shown*
Should be Empty:

Children's Ministry Family Information/Medical Release

Children Information

Medical Release

Insurance Information