Alaska 2023 Medical Release Form

Please fill out the medical release form below.

Student Names(Required)

Student Name

Grade

Add additional students by clicking the + icon

Parent Name(Required)

First Last

Cell Phone(Required)

Work Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Spouse or 2nd Parent Name(Required)

First Last

Cell Phone(Required)

Work Phone

Emergency Contact Information

Person to be called if neither parent can be reached

Contact Name

Relationship to Child

Cell Phone

Other Phone

Insurance Information

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

Insurance Company Name

Group #

Policy #

Cardholder Name

Insurance Company Phone Number

Please Upload Image of Front and Back of Insurance Card

Drop files here or

Max. file size: 32 MB.

**Tip** Take a picture with your phone

Doctor and Medical Information

Primary Care Physician's Name(Required)

Physician's Phone Number(Required)

Physical Limitations

Student Name

Please list any limitations, and/or Special Instructions

(Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.)
***Add additional students by clicking on the "+" icon***

Medications

Student Name

List "ALL" medications taken on a regular basis and/or brought with you

**Prescription medications MUST have a pharmacy label and name of doctor.***

Surgeries/Serious Injuries

Student Name

Surgeries/Injuries/Date

**Please list all surgeries/serious injuries and dates within the last 5 years.***

Please Read and Accept

Health History(Required)

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.

Medical Release(Required)

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.

Permission to Treat(Required)

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 (including giving prescription and over the counter medication) 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.

Medical Expense(Required)

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.

Liability(Required)

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).

Please print, provide current date and sign below

Full Name(Required)

Today's Date(Required)

Signature(Required)

Back to Alaska 2023 Main Page

Alaska 2023 Medical Release Form

Please fill out the medical release form below.

Emergency Contact Information

Insurance Information

Doctor and Medical Information

Please Read and Accept

Please print, provide current date and sign below

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