Medical Form for Students

Emergency Medical Release Form

First Congregational Church of Santa Cruz, UCC

900 High Street, Santa Cruz CA 95060   (831) 426-2010   www.fccsantacruz.org

Emergency Medical Release Form

Name   Gender   Age   DOB

Address   City   Zip

School   Grade

Parent1/Guardian Name

Home Phone   Work Phone   Cell Phone

Parent2/Guardian Name

Address (if different)   City   Zip

Home Phone   Work Phone   Cell Phone

Other Emergency Contact:   Relationship to youth

Home Phone   Work Phone   Cell Phone

Family Physician   Phone

Dentist   Phone

Eye Doctor   Phone

Date of most recent tetanus shot/booster   Glasses or contacts worn?

Allergies to medications? Please list

Any other allergies? (type, description of symptoms, etc)

Is emergency medication required for this allergy?

Does your child have any condition or limitation the leaders should know about to assure his/her well being at youth events and activities?

Please explain

Has your child had any major illness at any time which may affect his/her ability to participate in any activity? Please explain

Medical History Has your child been subject to any of the following? (Please check all that apply)

May the medical supervisor administer any of the following to your child?

I give my permission for my child to receive the above medications as indicated by the “Yes” column. Before treatment is provided for any other illness or injury, parental contact or physician advice will be sought. I will notify the Youth Leaders if my child is exposed to any communicable disease during the two weeks prior to attending any function.

IN CASE OF MEDICAL EMERGENCY, I give permission to the physician selected by the FCC Youth Leaders or their designees to secure proper treatment for or hospitalize, and order injection, anesthesia or surgery for my child named. (Every effort will be made to first contact parent or guardian)

I, the undersigned parent/guardian of the named minor, do hereby authorize First Congregational Church of Santa Cruz, UCC, as agent for the above named to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff at any hospital or medical care facility, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of a specific diagnosis, treatment or hospitalization being required but is given to provide authority and power on the part of my aforesaid agent to give specific consent to any and all such care. I hereby authorize any hospital, which has provided treatment to the above named minor pursuant to the health and safety provision for any and all States in the United States of America and to surrender physical custody of such minor to my above named agent upon the completion of treatment. These authorizations shall remain effective until September 30, 2009, unless revoked sooner in writing and delivered to said agents. A photocopy of this authorization shall have the same force and effect as the original.

TRANSPORTATION: Youth Leaders (over the age of 25) have my permission to transport my child to and from youth events

Yes   No

Printed Name:

Today’s Date