CEMI CHRIST IS THE ANSWER CHURCH

MEDICAL PERMISSION AND RELEASE FORM

(To be completed and notarized before departure)

NAME__________________________________________________BIRTHDATE_________________AGE____________
ADDRESS____________________________________________CITY___________________STATE_____ZIP_________
PHONE_____________________________________ EMAIL_____________________________________
In Case of Emergency Notify________________________________________ Phone______________________________
Family Physician___________________________________________Phone______________________________
Family Insurance Co._______________________________________ Policy #_____________________________
IMMUNIZATIONS: Tetanus__________ Polio Booster ____________Measles ___________Mumps__________
Other_________________________

PAST MEDICAL HISTORY

(Check giving appropriate information)

Asthma _______ Sinusitis _________ Bronchitis _________ Kidney Trouble ________ Heart Trouble _________
Diabetes______ Dizziness _______ Upset Stomach _______ Hay Fever ________ Other ___________
Allergies: (List type)
Food ________________________________________
Penicillin or other drug (Name) _____________________________________
Insect stings/bites _________________________________________
Poison sumac, oak or ivy ______________________________________
Previous operations or serious illness: ___________________________________________
Any current medications: (List) __________________________________________________
Special Diet: (Name) _______________________________________________________
Childhood Diseases: Chickenpox ___________ Measles ____________ Mumps _________
Whooping cough ___________ other ________________________

PERMISSION FOR TREATMENT AND DISCHARGE

My permission is granted for CEMI CHRIST IS THE ANSWER CHURCH staff member or sponsor in charge of the
__________________________________ (event) trip to ________________________________________ (location) on
______________________________________ (date) to obtain necessary medical attention in case of sickness or injury for
______________________________________ (Participants Name). I/We, the undersigned, do hereby release, and forever discharge
all sponsors and CEMI CHRIST IS THE ANSWER CHURCH from any and all claims, demands, actions or cause of action, past,
present, or future arising out of any damage or inquiry while participating in the event. We further accept financial and physical
responsibility for the return of our child(ren), should the adult supervision find it necessary to send him/her/them home (as applicable)

___________________________________________________________ ______________________
Signature of Parent Guardian Date

NOTARY_________________________________________________________________________________________________

THIS FORM MUST BE NOTARIZED FOR ALL PARTICIPANTS!