TEENS FOR CHRIST NW                                                                              
914 Citadel Dr
. #D       
Everson, WA  98247              

 MEDICAL RELEASE FORM for the season of  20     ____-20________

Name of Participant __________________________________________________________

Birth date ___________________  Age ___________ Phone # ________________________

Mailing Address _____________________________________________________________

City _________________________ State ________________ Zip _____________________

School _______________________________________ Grade ________________________

Parent(s) business or cell phones _________________ (dad) ______________________(mom)

Email Address _______________________________________________________________

To whom it may concern:
   The undersigned does hereby give permission for our (my) child, ____________, to attend and participate in the outings sponsored by Teens for Christ for the school year of 20___-20___.  We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray exams, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnoses or treatment is rendered at the office of a physician or at a hospital.

   The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

   Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

   The undersigned does also hereby give permission to our (my) child to ride with any adult in whose care the minor has been entrusted.  

Father’s name _______________________________      Mother’s Name _____________________________

Legal Guardian _______________________

Hospital Insurance?    Yes    No

Insurance Company ___________________________  Policy Number ____________________________­­­­­­­­_________

Signature of Guardian ____________________________________________________ Date ___________________

Please list any allergies or special medical problems your child has _________________________________________

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