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Medical release forms 2013

FARLEY COMMUNITY CHURCH YOUTH MINISTRY, HUNTSVILLE, ALABAMA
2013 HEALTH AND LIABILITY RELEASE FORM – FOR YOUTH AND YOUNG ADULTS
(This form is for youth and young adults, up through age of 20. If your parents insure you, you should use this
form.)
Name_____________________________Birthdate________________Age_______Home Phone_______________
Address, C-S-Z_________________________________________________________________________________
Parents___________________________________ Cell Phone - His____________________
Hers__________________
1. Does your young person have any allergies or asthma? (Include foods, plants, bee stings, pets, medications, etc.)
Please also indicate how should we treat.
2. ___Yes___No My young person may receive the following from the staff from our first aid kit:
(Please cross out what we should not give to your young person.)
These brands or similar brands: Tylenol, ibuprofen, Aleve, Pepto-Bismol, Tums, Sudafed-decongestant,
Benadryl-antihistamine, Robitussin-cough suppressant, Caladryl, Neosporin.
3. Do you want your youth to carry and self-administer any medications? If so, please list what medications:
4. List any other medical conditions the staff should be aware of with instructions on how we should treat.
(fainting, sleep walking, heart condition, back problems, female concerns, etc.)
5. Indicate young person's swimming ability: (be very honest)
A. Cannot swim. B. Can swim, but less than 50 feet. C. Swims OK. D. Strong swimmer. E. Trained Life Saver.
6. MEDICAL & EMERGENCY INFORMATION: Please list the date of last tetanus shot:____________________
Doctor ________________________________ Phone ______________
Insurance Company _____________________________ Policy # ___________________
In case of an emergency, we will call the numbers listed above.
If no answer, please reach me at _________________________________Phone___________________
Then, if no answer, please call my friend/relative_______________________________Phone__________________
Address ____________________________________________________________
7. EMERGENCY PROCEDURE AGREEMENT: IN THE EVENT OF ANY EMERGENCY, LEADERS WILL
ATTEMPT FIRST TO CONTACT YOUR FAMILY &/OR DOCTOR. In the event that this is impossible, please
note below:
___Yes___No 1. With my signature below, I hereby authorize First Aid by staff or other adults.
___Yes___No 2. With my signature below, I hereby authorize emergency medical care by hospital staff and/or
doctor selected by staff or other adults.
___Yes___No 3. With my signature below, I authorize physician selected by staff or other adults to hospitalize,
secure proper treatment for, and to order injection, anesthesia, or surgery.
If parent has answered "No" to either 1, 2, or 3 above, you must indicate the procedure to be followed in event we
are not able to contact parent:
8. RESPONSIBILITY AGREEMENT: Farley Community Church and its Youth Ministry is committed to provide
a wholesome and safe program. If an accident/injury/illness should occur, however, I do have medical insurance for
my youth. If there is no insurance or only limited coverage, I assume all financial/medical responsibility. I also
release Farley Community Church and personnel, (staff, counselors, adult & youth leaders) from liability.
9. PHOTO RELEASE AGREEMENT: I give Farley Community Church and its Youth Ministry permission to use
photos of me or my family members for public display or for our website. ____Yes ____No
WITH MY SIGNATURE, I AGREE: A. That the information on this entire form is correct to the best of my
knowledge. B. I agree with #7, #8, #9 as indicated above; C. that this form shall be valid for any Farley Community
Church Youth outings, events, retreats or trips from January 1, 2013 - December 31, 2013, and D. that I will
promptly update this information if different conditions arise during this indicated time after this form is turned in.
Date____________ Parent Signature___________________________________
Date___________ Notary’s Signature_______________________________ My commission expires _________

FARLEY COMMUNITY CHURCH YOUTH MINISTRY, HUNTSVILLE, ALABAMA
2013 HEALTH AND LIABILITY RELEASE FORM – FOR ADULTS
(IF YOU ARE OVER 21 AND/OR YOU CARRY YOUR OWN INSURANCE, you should use this form.)
Name_____________________________Birthdate________________Age_______Home Phone_______________
Address, C-S-Z_________________________________________________________________________________
Cell Phone - His____________________ Hers____________________
1. Do you have any allergies or asthma? (Include foods, plants, bee stings, pets, medications, etc.)
Please also indicate how you treat.
2. Our first aid kit contains these brands or similar brands listed below. Please cross out any of these that you should
not have: Tylenol, ibuprofen, Aleve, Pepto-Bismol, Tums, Sudafed-decongestant, Benadryl-antihistamine,
Robitussin-cough suppressant, Caladryl, Neosporin.
3. Do you carry and self-administer any medications? If so, please list what medications:
4. List any other medical conditions the staff should be aware of with instructions on how we should treat.
(fainting, sleep walking, heart condition, back problems, female concerns, etc.)
5. Indicate your swimming ability: (be very honest)
A. Cannot swim. B. Can swim, but less than 50 feet. C. Swims OK. D. Strong swimmer. E. Trained Life Saver.
6. MEDICAL & EMERGENCY INFORMATION: Please list the date of last tetanus shot:____________________
Doctor ________________________________ Phone ______________
Insurance Company _____________________________ Policy # ___________________
In case of an emergency, we will call the numbers listed above.
If no answer, please call _________________________________Phone___________________
Address ____________________________________________________________
Then, if no answer, please call _________________________________Phone__________________
7. EMERGENCY PROCEDURE AGREEMENT: IN THE EVENT OF ANY EMERGENCY, LEADERS WILL
ATTEMPT FIRST TO CONTACT YOUR FAMILY &/OR DOCTOR. In the event that this is impossible, please
note below:
___Yes___No 1. With my signature below, I hereby authorize First Aid by staff or other adults.
___Yes___No 2. With my signature below, I hereby authorize emergency medical care by hospital staff and/or
doctor selected by staff or other adults.
___Yes___No 3. With my signature below, I authorize physician selected by staff or other adults to hospitalize,
secure proper treatment for, and to order injection, anesthesia, or surgery.
If you have answered "No" to either 1, 2, or 3 above, you must indicate the procedure to be followed in event we are
not able to contact your family:
8. RESPONSIBILITY AGREEMENT: Farley Community Church and its Youth Ministry is committed to provide
a wholesome and safe program. If an accident/injury/illness should occur, however, I do have medical insurance. If
there is no insurance or only limited coverage, I assume all financial/medical responsibility. I also release Farley
Community Church and personnel, (staff, counselors, adult & youth leaders) from liability.
9. PHOTO RELEASE AGREEMENT: I give Farley Community Church and its Youth Ministry permission to use
photos of me or my family members for public display or for our website. ____Yes ____No
WITH MY SIGNATURE, I AGREE: A. That the information on this entire form is correct to the best of my
knowledge. B. I agree with #7, #8, #9 as indicated above; C. that this form shall be valid for any Farley Community
Church Youth outings, events, retreats or trips from January 1, 2013 - December 31, 2013, and D. that I will
promptly update this information if different conditions arise during this indicated time after this form is turned in.
Date____________ Signature__________________________________
Date____________ Notary’s Signature________________________________ My commission expires _______

Source: http://www.farleycc.org/uploads/2/8/3/9/2839535/medical_release_form_2013.pdf

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