Rcc - medical release

RCC Medical Release/Liability Waiver/Insurance Form
August 1, 2010 through August 31, 2011 NAME: __________________________________________________________________________
DATE OF BIRTH: _______________________________ PHONE: _____________________________
ADDRESS: _____________________________________________________________________

I give my permission for my child (named above) to go with Rockingham Christian Church, Salem, NH, on congregation sponsored activities. I release Rockingham Christian Church, and its staff and volunteer leaders, from responsibility and liability for any injury or illness that my child/children may sustain during these activities. IN CASE OF EMERGENCY, I hereby authorize an adult leader of this activity, as an agent for me, to consent to any X-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a
physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state or country where the
services are rendered, either at a doctors office or in any hospital. I expect to be contacted as soon as possible and
before hospitalization or surgery is administered (unless the injury or il ness is life threatening).

Signature of parent/legal guardian: ______________________________________________________________

to food: ____________________________________ to medications: _________________________
to insect bites/stings: _________________________ to others (list): _________________________
Medications taken currently: __________________________________________________________________________
Date of last Tetanus Booster: ________________________________ (must have been within the last 10 years)
Please cross out any medication you do not allow your child to have:
Pain Relievers (Tylenol/Acetaminophen, Ibuprofen, aspirin, other _____________________________) Allergy Medication (Benadryl, other antihistamines, other ___________________________________) Cough Suppressants (__________________________________________) Decongestants (Sudafed, other ________________________________) Anti-diarrhea Medications (Pepto Bismol, Immodium, other ___________________________________) Other over the counter medications _____________________________________________________ Physical limitations/Current health conditions: __________________________________________________ Physician's Name: ______________________________________________________ Address: _________________________________________________________________________ Telephone Number: ___________________________________________ PLEASE ATTACH PHOTOCOPY OF INSURANCE CARD
Insurance Company: ________________________________________________________________________ Name of Insured: _________________________________________________________________ Policy #: ________________________ Group #: ______________________ Phone #: ________________________ Emergency Contact Information Print name of parent/legal guardian: ____________________________________________________________ Phone #s of parent/legal guardian: Home _____________________ Work _________________ Cel ________________ Names of other emergency contact person(s) and phone number(s): 1st _________________________________________________ Phone Number(s): _____________________________ 2nd _________________________________________________ Phone Number(s): _____________________________ 3rd _________________________________________________ Phone Number(s): _____________________________

Source: http://xtremegrace.net/~students/wp-content/uploads/2010/09/rcc-medical-release-pdf.pdf

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