Uprising Medical Release Form

Gateway Community Church Student Medical Information Form STUDENT INFORMATION Name: _____________________________ Birthday _________________ Age: ______ Address: ____________________________ ____________________________________ School & Grade: ______________________ Home Phone: ________________________ EMERGENCY INFORMATION First Emergency Contact: Name: _______________________________ Relation: _____________________________ Home Number: ________________________ Work Number: _________________________ Other Number: _________________________ Second Emergency Contact: Name: _______________________________ Relation: _____________________________ Home Number: ________________________ Work Number: _________________________ Other Number: _________________________ Student’s Physician: _____________________ Address: ______________________________ ______________________________________ Phone Number: _________________________ Family Insurance Company: _______________ Policy Number: _________________________

Current Medication: _________________________ Special Diet: _______________________________

PERMISSION & RELEASE FORM I hereby grant permission for my child, _____________________, to attend off campus activities sponsored by Gateway Community Church. I also acknowledge that Gateway Community Church is not responsible for injury or loss of personal belongings on these trips. In the event that my child becomes ill or injured while under the church’s supervision, I authorize the leader or their designee to take the following steps: 1) Contact the parents of the child IMMEDIATELY and follow his or her instructions. 2) In the event that neither parent can be reached, GCC will contact the 2nd emergency contact and/or the child’s physician and follow their instructions. In the event that these contacts cannot be reached, GCC will use their discretion in contacting a properly licensed practicing physician.

 Tetanus  Measles  Mumps  Polio Booster  Other________________________

3) If, in his or her opinion, the child needs medical or surgical services which require the parents’ consent and the parents cannot be reached, I, the parent, hereby authorize, appoint, and empower the leader or their designee to furnish on my behalf such written or oral authorization as may be required.

Please check the appropriate info:

4) I release the leader or their designee and GCC

MEDICAL HISTORY Immunizations:

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Asthma  Diabetes  Heart Trouble Bronchitis  Sinusitis  Dizziness Hay Fever  Kidney Trouble  Social Disorders Stomach Trouble  Other______________________

Allergies (please list): Foods: ___________________________________ Drugs: ___________________________________ Insect Stings/Bites: _________________________ Plants: ___________________________________ Previous Operations: ________________________ Previous Serious Illnesses: ___________________

and/or agent thereof from any liability which might arise from the granting of such authorization, since it is my desire that my child receive medical attention as soon as possible. Signature of Parent or Guardian: _______________________________ Date: __________________________