NextGen Medical Release for Student Ministry Travel

Student Name

First Name

Last Name

Date of Birth

YYYY

Emergency Contact Name

First Name

Last Name

Ermergency Contact Phone

(###)

###

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Medical Release

All information provided on this form is correct to the best of my knowledge. In case of emergency or illness, I understand that every effort will be made to contact the Emergency Contact for my child. I give group leaders of Thanksgiving Church permission to seek medical treatment for my child in case of emergency. I give the above leader(s) permission to provide my child with medical treatment which may include, but is not limitedto : the use of Tylenol, Ibuprofen, Benadryl, Rolaids, Cough Medicine, Chlorpheniramine(allergy medication), Benadryl Cream, Caladryl, Triple Antibiotic Ointment, Sudafed, Claritin, or generic equivalents to these medications, physician consultation, urgent, emergency, and non-emergency medical treatment. I agree to indemnify and hold harmless Thanksgiving Churchand it’s leaders, staff, employees, members, agents, vehicle owners, vehicle drivers, trip sponsors, council members, and any other parties, volunteering on behalf of Thanksgiving Churchfrom any and all claims, damages, losses, or injuries and expense arising out of or resulting from my child’s participation in Ministry Travel activities.

Initials

Medical Release and Consent to Emergency Medical Treatment

I authorize Group Leaders Names from Thanksgiving Church, in whose care my child has been entrusted, to consent to any X-ray examination, diagnosis and/or treatment (i.e. anesthetic, medical, surgical, or dental), or hospital care to be rendered to my child under the general or special supervision and on the advice ofany physician or dentistlicensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether diagnosis or treatment is rendered at the office of a physician or the hospital, I shall be liable and agree to pay allcosts and expenses incurred in connection with such medical/dental services rendered. This authority is granted only after a reasonable attempt has been made to contact me or in a life-threatening situation.

Insurance Information

Subscribers Date of Birth

YYYY

Insurance Company Name & Policy Number

Insurance Company Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company Phone Number

(###)

###

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Primary Physician Name

First Name

Last Name

Primary Physician Phone Number

(###)

###

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