Medical Release

	Please fill all required fields (*)
Parent/Guardian Full Name (*)	Invalid Input
Phone Number (*)	Invalid Input
E-mail Address (*)	Invalid Input
Home Address (*)	Invalid Input
Minor Child Full Name (*)	Invalid Input
Child's Address if different then above	Invalid Input
Birthdate (*)	Invalid Input
Current Grade (*)	Invalid Input
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	Alternate Emergency contact We will always try to contact parents/guardians first.
Name (*)	Invalid Input
Phone Number (*)	Invalid Input
	Full names of authorized person(s) who may pick up my child: Please notify teacher or event leader if child will be picked up by one of these authorized persons. If there is a person who may NOT pick-up your child due to court order (such as a parent or close family member), please notify the church office and provide a copy of the court order.
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Please list any food, medication or other allergies your child has:	Invalid Input
Does your child have any special educational or behavioral needs?	Invalid Input
This child wears	GlassesContact lensesHearing AidOther Invalid Input
Are there additional concerns we should know about?	AsthmaDiabetesEpilepsy/Seizure disorderOther Invalid Input
Please describe	Invalid Input
	Insurance Information – complete any or all that apply
Company	Invalid Input
Group Number	Invalid Input
Policy Number	Invalid Input
Physician Name	Invalid Input
Physician Phone	Invalid Input
Signature (*)	By checking this box, I/we certify that I/we have legal custody of the minor child named on this form and give consent for ministry leaders at Batavia United Methodist Church and Flowing Grace to seek medical attention deemed necessary. All staff and ministry volunteers of Batavia United Methodist Church and Flowing Grace are released from liability against personal losses of minor named above. (check box) I/we understand that there are inherent risks involved in any ministry event and release the church, its pastors, employees, agents and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. (check box) In the event that the minor child is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. I/we acknowledge that I/we will be ultimately responsible for the cost of any medical care should the cost of that care not be reimbursed by the health insurance provider. (check box) I/we also agree to bring my/our child home at my/our expense should they become ill or if deemed necessary by the Batavia United Methodist Church staff or volunteer staff. Invalid Input