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.
Confirmand's Name*
First Last
Birthdate*
Address*
Street Address City State ZIP Code
Parent Information
Parent/Legal Guardian*
First Last
Relationship to Student*
Primary Phone*
Parent/Guardian Primary Phone*
Parent/Guardian Secondary Phone*
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.
Non-Parent Emergency Contact*
First Last
Relationship to Confirmand*
Emergency Contact Primary Phone*
Emergency Contact Secondary Phone*
Insurance & Doctor Information
Primary Medical Insurance Company*
Policy #*
Group # and/or Member #

optional
Policy Holder's Full Name*
Policy Holder's Employer

optional
Student's Primary Care Physician*
Physician's Phone*
Confirmand's Dentist*
Dentist's Phone*
Please describe any allergies or known medical conditions.
Date of last tetanus shot*
Signature of Parent or Legal Guardian*
First Last

Entering your name here acts as an electronic signature to this form.
Today's Date*
MM slash DD slash YYYY
Primary Email Address*

A confirmation email will be sent to this email address upon completion of form.

Parent Information

Emergency Contact

Insurance & Doctor Information

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