Medical Release and Event Permission for all events in 2019:

In the event of a medical emergency, procedures must be clearly outlined and understood by both parents and leaders.  If you list the names of all your children on this form, it will not be necessary to complete a separate form for each child.

Child/Childrens Name(s) *
Child/Childrens Name(s)
Address *
Address
Cell Phone *
Cell Phone
Home Phone *
Home Phone
Parent/Gaurdian's Name *
Parent/Gaurdian's Name
In the event of illness or medical emergency, the leader will attempt to contact parents for instructions. If the leader is unable to contact you, the leader will have the authority to have the child treated by any licensed physician and/or surgeon who may perform such procedures or administer such medications as the emergency requires for the relief of pain or to preserve life and health. In non-medical emergencies, the leader will take what action seems to be normal and appropriate.
Parent/ Gaurdian's Phone *
Parent/ Gaurdian's Phone
Parent/ Gaurdian's Name 2
Parent/ Gaurdian's Name 2
Parent/ Gaurdian's Phone 2
Parent/ Gaurdian's Phone 2
Doctor's Phone *
Doctor's Phone
Would You Like To Use Parent Information as Emergency Contact? *
If No: Please enter emergenct contact information here:
If No: Please enter emergenct contact information here:
Emergency Contact Phone
Emergency Contact Phone
By signing at the bottom of this page, I hereby agree that I have read the above policy and am in agreement with its provisions in total. I also assume financial responsibility for use of an ambulance to transport my child to the nearest health care facility should such a need arise. *
Please Print Full Name Below- This will be your Digital Signature