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Person to be called if neither parent can be reached
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Insurance Information
***A scanned/image of Insurance Card must be attached to this form***
Insurance Company Name
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Cardholder Name
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Please Upload Image of Front of Insurance Card
Max. file size: 256 MB.
**Tip** Take a picture with your phone
Please Upload Image of Back of Insurance Card
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Doctor and Medical Information
Primary Care Physician's Name
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Physician's Phone Number
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Physical Limitations
Student Name
Please list any limitations, and/or Special Instructions
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(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
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**Prescription medications MUST have a pharmacy label and name of doctor.***
Surgeries/Serious Injuries
Student Name
Surgeries/Injuries/Date
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**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).
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