Elevate Medical Release Form- Student

This medical emergency form must be completed and initialed by the parent or guardian and accompany the youth who wishes to participate in Elevate activities. The purpose of this form is to make it possible for parents or guardians to authorize the provision of medical treatment for minors who become ill or injured while under the supervision of Elevate activities.

Your name *

Email address *

Student's Name *

Relationship to Student

Address *

Phone Number *

Student's Birthday *

Allergies, Medication taken on a regular basis, Physical Impairments, and other important information *

Date of Last Tetanus shot *

Insurance Company *

Group Name/Group Number *

Policy Number *

Name of Policy Holder *

Date of Birth of Policy Holder *

Emergency Contact Name *

Please give us the name of a person we can call in the event an emergency occurs and we are unable to reach you.

Emergency Contact Phone Number *

As the parent/ guardian, I give my permission for an Elevate Ministry Leader, at their discretion, to administer over the counter medication(s) as needed to my child. *

Yes, I give my permission

No, I do not give my permission

Disciplinary Agreement *

I understand that, while my student participates in the Elevate activities, he or she is responsible to abide by the rules set forth by the leaders and supervisory personnel. Any serious inflation of these rules and/ or disregard of leadership by him/ her can result in dismissal from the program or event. If he/ she is dismissed from the program or event, I agree to assume the cost and responsibility of him/ her returning home, and of any damages which may have been caused by him/ her.

Yes, I give my permission

No, I do not give my permission

I understand that my initials act as an electronic signature. I authorize any Elevate representative to consent to medical or dental treatment for my children if they become ill or injured while under the supervision of Elevate activities. *

I verify all information is correct to the best of my knowledge. This medical emergency form must be completed and initialed by the parent or guardian and accompany the youth who wishes to participate in Elevate activities, including activities off of the church campus.

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