Confirmation Class Medical Release

Confirmation Class Medical Release

  • This form is valid for all class activities from August 2018 through May 2019.

    I hereby release First Presbyterian Church and its staff and sponsors from responsibility and liability for any injury or illness that my child may sustain during church-sponsored activities. In the event of an emergency, I hereby authorize an adult leader of the activity, as agent for me, to consent to any examination or treatment by physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible.
  • Parent Information

  • Emergency Contact

    Parent/legal guardian will be contacted first in case of emergency. In case parent/guardian cannot be reached, please provide a non-parent emergency contact.
  • Insurance & Doctor Information

  • optional
  • optional
  • Entering your name here acts as an electronic signature to this form.
  • A confirmation email will be sent to this email address upon completion of form.
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