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Microsoft word - the oneevent permission slip-health form

Great Plains Annual Conference of The United Methodist Church
The OneEvent 2014
MEDICAL RECORD AND LIABILITY RELEASE FORM
(Each person must bring this form with them in order to register. Persons without a form will not be able to attend.)
Date of conference: January 4-5, 2014 Church: _______________________________________ Date signed: ______________
SECTION 1: MEDICAL RECORD AND INSURANCE
Full Name: ______________________________________________________ Date of birth: _____________________________ Address: __________________________________________________________________________________________________ City/State/Zip: ___________________________________________________ Home phone: (______) _____________________ MEDICAL INSURANCE INFORMATION
Is this person covered by a medical insurance policy? Yes _______________ No ______________ Name of policy holder: ____________________________________________ Relationship to participant: __________________ Insurance company: ____________________________________________ Medical insurance policy number: ____________________________ Check one: Group plan: _____ Individual/Family plan: _____ MEDICAL HISTORY
Blood Type: ____________________ List allergies or allergies to medications: __________________________________________________________________________ ____________________________________________________________________________________________________________ List medication(s) presently taking: _______________________________________________________________________________ ____________________________________________________________________________________________________________ Please describe any medical problems or conditions including mental & emotional: __________________________________________ ____________________________________________________________________________________________________________ List any restrictions on sports or physical activity: ____________________________________________________________________ ____________________________________________________________________________________________________________ I hereby give permission for the person listed above to be treated with the following medications: (Check medications you approve for this person to receive) _____ Acetaminophen (temp/pain reliever) _____ Suphedrine (Sudafed/allergy) _____ Ibuprofen (temp/pain reliever) _____ Diphenhydramine (Benadryl/allergy) _____ Loperamide (Antidiarrheal) _____ Guaifenesin (Robitussin/Cough Syrup) List any medications person should not have: _______________________________________________________________________ ____________________________________________________________________________________________________________ Doctor’s name: ________________________________________________ Doctor’s phone: (_____) _____________________ SECTION II: MEDICAL TREATMENT RELEASE AND LIABILITY RELEASE
I, the undersigned parent or guardian (or self if adult 21 or over), do hereby grant permission for ______________________________to
attend the The OneEvent. I hereby authorize the event staff to obtain and consent to medical treatment for my child in case of injury or
illness during the The OneEvent. I hereby release and discharge the event staff, the Great Plains Conference of the United Methodist
Church, the leaders and staff of __________________ Church and the United Methodist Church and its representatives, employees,
volunteer staff, and agents from any and all debts, judgments, or suits of any kind which may arise or be occasioned as a result of the
participant’s participation in the The OneEvent, including transportation to and from the event.
I further acknowledge and understand that by participating in the The OneEvent there is a possibility of physical illness or injury and my
child (or self if 21 or over) is assuming the risk for such illness or injury by his/her/my participation. It is my understanding that payment
of any medical bills will be paid by me or by my insurance company.
___________________________________________________ _____________________________________________________
Signature of Parent, Guardian, or self if 21 or over Name of Parent, Guardian, or self (printed) ___________________________________________________ (_______) ____________________________________________ ___________________________________________________ (_______) ____________________________________________ Alternate person to call in case of an emergency Rev. 7/2013

Source: http://greatplainsyouth.org/files/2013/12/OneEventHealthForm.pdf

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