KOZ Medical Release Form

KOZ Medical Release Form

Parents voluntarily register their children for participation in outdoor training classes. Parents are required to complete and sign the medical release form for each child registered to participate. Children will not be accepted into the program without this completed and signed form.
Child's Name: *

First Name Last Name
Person to contact in Emergency: *
Relationship *
Phone Number *

Area Code Phone Number
Medical File Information
Your family physician or medical office:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Does your child have health problems we need to be prepared for? *
Is your child on medication: Yes or No If yes, please list all medications:
Medical Insurance Coverage? Yes or No Company Name:
Policy number:
I hereby release CORNERSTONE CHURCH OF AUGUSTA and camp staff from responsibility in case of illness, accident, or injury. I further give permission to any physician, hospital, or other medical facilities to provide treatment to my child in the event of a medical emergency.
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Today's Date
This Medical Form will be kept on file for 1 year from filed date. Please notify Brian Fridley or Pastor Seth if any changes to child's medical information occur within the 1 year period.
Should be Empty:

Medical File Information