Medical Release Form | Hope Point Church

Medical Release Form / Permission to Treat

This Release Form is Valid for One Year from Date Notarized

Name of Church

City/State

Personal Information

First Name

Last Name

SSN#

Date of Birth

Address

City

State

Zip Code

Emergency Contact Information

Parent/Gaurdian Name

Phone

Work Phone

Secondary Contact Name

Relationship

Phone

Work Phone

Insurance Information

***A scanned/image of Insurance Card must be attached to this form***

Insurance Company Name

Group #

Policy #

Cardholder Name

Relationship to Cardholder

Insurance Company Full Address

Insurance Company Phone Number

Please Upload Image of Insurance Card

Upload

Physician's NamePrimary Care

Physician's Phone Number

Physical Limitations(Asthma, diabetes, allergies, etc.), and/or Special INstructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):

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List ALL Medication taken on a regular basis and/or brought with you.(Prescription meds MUST have a pharmacy label and name of doctor.)

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List all operations/serious injuries and dates within the past five (5) years

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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.

I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity.

I hereby give permission to medical personnel selected by the participants Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above.

I understand that if I do not have medical insurance, I, as the parent or guardian, or I as an individual eighteen years of age or older, will be responsible for any medical expenses in the event of a sickness and/or injury.

I understand that there are risks involved while participating in recreational activities and other activities related to youth and/or church functions and in this knowledge I release Hope Point Church and The Broadcast Student Movement from any and all liability for injuries and/or incidents I may incur during such activities within the covered period (one year).

The portion below will be completed in the presence of a Notary Public.

Signature of Individual (if 18 or older) ______________________________________

Date ________________________________________________________________

Signature of Parent/Guardian (if younger than 18) _______________________________

Date __________________________________________________________________

The following should be completed by the notary witnessing parent/guardian s signature.

The State of South Carolina the County of Spartanburg Before me, a Notary Public, on this day personally appeared ____________________ known to me (or proved to me on the oath of ______________________ to be the person whose name is subscribed to the foregoing instrnment and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this _______ day of _________ , A.D. __________.

Notary Public, Signature __________________________________________________

My commission expires the _________ day of ___________, A.D. _________________

This Release Form is Valid for One Year from Date Notarized

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