Living Gospel - rise yth medical release form

student info

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Birthdate

Email

Grade

Phone Number

emergency info

phone numbers where our youth ministry leaders can reach a parent or an emergency contact for the child named above during scheduled events

Parent/Legal Guardian

Last Name

Phone Number

Work Number

Emergency Contact

Last Name

Phone Number

medical info

In case of Medical Emergency I understand that, in the event medical treatment is required, every effort will be made to contact me or the emergency contact person. However, if I cannot be reached, I give permission to the staff to secure the services of a licensed physician to provide the care necessary, including hospitalization, anesthesia, injection, or surgery for my child’s well - being. I hereby agree to indemnify and hold harmless Living Gospel Church, its employees, and volunteer staff from any liability.

parent/guardian's insurance group name or write self-pay

insurance group number

family physician's name

family physician phone number

date of last tetanus shot

allergies, conditions, dietary restrictions, special needs, medical concerns of which we should be aware:

my child requires the following medicine:

my child has permission to be given tylenol or ibuprophen if they request it

parental permission and release form

My child has my permission to participate with the Living Gospel Youth to Romania on a Rise Youth Mission Trip on June 22, 2025 through June 30, 2025. I hereby agree to indemnify and hold harmless Living Gospel Church, its officers, employees, and volunteer staff from any liability. I accept responsibility for any medical expenses as a result of any such injury sustained.

Signature

medical release

To Whom It May Concern: As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor for my child in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. This release is intended for 6/22/25 - 6/30/25. This release form is completed and signed of my own freewill with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signature

living gospel youthparental permission and release form

student info

emergency info

phone numbers where our youth ministry leaders can reach a parent or an emergency contact for the child named above during scheduled events

medical info

parental permission and release form

medical release

living gospel youth
parental permission and release form