Central Students Medical Release Form
* First Name
* Last Name
* Name of Participant
* Campus Attending
Select one
Central Campus
Paragould Campus
SS# (optional)
* Birth Date
* Age
* Gender
Female
Male
* Address
* City
* State/Province
* Zip/Postal Code
* Emergency Contact Info - Parent/Guardian Name
* Cell Phone
* Work Phone
* Secondary Contact Name
* Relationship
* Parent/Guardian Cell #
* Work Phone
* Do you have medical insurance?
Select one
Yes
No
* Name of Insurance Company
* Insurance Group #
* Insurance Policy #
* Name of Insurance Cardholder
* Relationship to Insurance Cardholder
* Insurance Company Address
* Insurance Company Phone Number
* Primary Care Physician's Name
* Primary Care Physician's Phone Number
* Physical Condition
Select one
Fair
Good
Excellent
* Physical Limitations (asthma, diabetes, allergies, etc.), and/or Special Instructions (allergic to certain meds, rare blood type, wears contact lenses, etc.)
* List ALL medication taken on a regular basis and/or any brought with you. (Prescription meds MUST have a pharmacy label and name of doctor.)
* Please tell us anything else we need to know about your medical history.
* The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.
Select one
Yes
No
* I hereby give permission to medical personnel selected by the participant's Church sponsor/his designee staff to order X-rays, routine tests, and treatment for my participant. In the event of an emergency and neither my primary contact nor secondary contact can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order inje
Select one
Yes
No
* I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company.
Select one
Yes
No
* In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity.
Select one
Yes
No
* I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.
Select one
Yes
No
* I understand that there are risks involved in taking part in recreation activities and other activities related to participation in youth functions.
Select one
Yes
No
* Print Name of Parent/Guardian
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