Ski Trip Medical Release
For PROTECTION INFORMATION :
Name: Last______________________First____________________
Middle____________Preferred name:____________________________________
Age:__________Sex:___________ Birth Date:__________
Favorite things to do :________________________________________
Address:_____________________________________________________
City:___________________________State:________Zip:_____________________
Phone number at home:___________________
E-mail address:___________________________
*EMERGENCY CONTACT CHOICE 1
Name:_______________________________________________
Phone:___________________
Relationship to child:___________________________________________________
*
EMERGENCY CONTACT CHOICE 2
Name:_______________________________________________
Phone:___________________
Relationship to child:___________________________________________________
*MEDICAL INFORMATION
HOSPITAL PREFERENCE:________________________________________________
Family Doctor:_______________________________________Phone:____________
Insurance Company:__________________________________Phone:____________
Policy Number:________________________________________________________
Social Security #:________________________________________________
*HEALTH HISTORY: List anything pertinent to your child’s
performance in any activity.
Any allergies?______To what?___________________________________________
Dietary modifications if any:_____________________________________________
Asthma?________ Seizures?_______ Diseases?__________
Tendency to faint?_______________
Loss of hearing?_________________Bleeding/Clotting problems?_______
Learning disabilities?___________Shots/Vaccinations up to date?______
Current or permanent medications we should be aware of?
________________________________________________________________________
Please use this space for further information we need to know concerning any of
the above or anything else that could help us take better care for you.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
* MEDICAL RELEASE/ PERMISSION
If a medical emergency should arise, I hereby give
permission to the person in authority to select the physician, nurse, or other
member of the medical profession and/or hospital listed for my child’s care
and to proceed with the necessary steps. I will assume liability of payment
for all such persons and such services rendered and will exclude Arlington
United Methodist Church for any expenses incurred for treatment, care,
medications, and other services. I give permission to be sent home at my
expense for any misconduct on the trip. In consideration for the above as
well as in consideration for the supervision and discipline provided, I hereby
agree to indemnify and hold harmless and not responsible Arlington United
Methodist Church of Jacksonville, Inc., its agents, members, employees,
counselors, and affiliates (herein collectively referred to as AUMC ) for the
results of any decision which they in their discretion shall make.
I have received proper information of where departure time, what to bring,
and arrival destination.
Ski Trip (Timberline West Virginia)
This release contains the entire Agreement between the parties hereto
and the terms of this Release are contractual and not a mere recital.
I have carefully read, clearly understand, and voluntarily sign this release:
Releasor: (Please print):_____________________________________________
Releasor: (Signature):________________________________________________
STATE OF FLORIDA
DUVAL COUNTY The foregoing instrument was acknowledged
Before me on this date:
___________________________________
By: (Print name of person):___________________________________
Who is personally known to me
or has produced identification and did not take an oath.
Type of ID:__________________________
Notary signature:_____________________
Stamp or seal Notary name printed:__________________
My commission expires on:_____________
My commission number is:______________
Arlington United Methodist Church: November 2006
