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Peninsula-delaware conference of the united methodist church

Peninsula-Delaware Conference of the United Methodist Church
1 Day Service Project 2014
MEDICAL RECORD AND LIABILITY RELEASE FORM
(Each person must bring this form with them in order to register. Persons without a form will not be able to attend.)
Date of conference: April 5, 2014 Church: _________________________________________ Date signed: _______________
SECTION 1: MEDICAL RECORD AND INSURANCE
Full Name: ______________________________________________________ Date of birth: _____________________________ Address: __________________________________________________________________________________________________ City/State/Zip: ___________________________________________________ Home phone: (______) _____________________ MEDICAL INSURANCE INFORMATION
Is this person covered by a medical insurance policy? Yes _______________ No ______________ Name of policy holder: ____________________________________________ Relationship to participant: __________________ Insurance company: ____________________________________________ Medical insurance policy number: ____________________________ Check one: Group plan: _____ Individual/Family plan: _____ MEDICAL HISTORY
Blood Type: ____________________ List allergies or allergies to medications: __________________________________________________________________________ ____________________________________________________________________________________________________________ List medication(s) presently taking: _______________________________________________________________________________ ____________________________________________________________________________________________________________ Please describe any medical problems or conditions including mental & emotional: __________________________________________ ____________________________________________________________________________________________________________ List any restrictions on sports or physical activity: ____________________________________________________________________ ____________________________________________________________________________________________________________ I hereby give permission for the person listed above to be treated with the following medications: (Check medications you approve for this person to receive) _____ Acetaminophen (temp/pain reliever) _____ Suphedrine (Sudafed/allergy) _____ Ibuprofen (temp/pain reliever) _____ Diphenhydramine (Benadryl/allergy) _____ Loperamide (Antidiarrheal) _____ Guaifenesin (Robitussin/Cough Syrup) List any medications person should not have: _______________________________________________________________________ ____________________________________________________________________________________________________________ Doctor’s name: ________________________________________________ Doctor’s phone: (_____) _____________________ SECTION II: MEDICAL TREATMENT RELEASE AND LIABILITY RELEASE
I, the undersigned parent or guardian (or self if adult 21 or over), do hereby grant permission for _______________________________
to attend the 1 Day Service Project. I hereby authorize the event staff to obtain and consent to medical treatment for my child in case of
injury or illness during the 1 Day Service Project. And I hereby release and discharge the event staff, the Peninsula-Delaware
Conference of the United Methodist Church, and the United Methodist Church and its representatives, employees, volunteer staff, and
agents from any and all debts, judgments, or suits of any kind which may arise or be occasioned as a result of the participant’s
participation in the 1 Day Service Project.
I further acknowledge and understand that by participating in the 1 Day Service Project there is a possibility of physical illness or injury
and my child (or self if 21 or over) is assuming the risk for such illness or injury by his/her/my participation. It is my u nderstanding that
payment of any medical bills will be paid by me or by my insurance company.
___________________________________________________
_____________________________________________________ Signature of Parent, Guardian, or self if 21 or over Name of Parent, Guardian, or self (printed) ___________________________________________________ (_______) ____________________________________________ ___________________________________________________ (_______) ____________________________________________ Alternate person to call in case of an emergency Rev. 3/2010

Source: http://www.pen-del.org/console/files/oFiles_Library_XZXLCZ/1_Day_Service_Project_2014_Health_Form_PDF_5XJZSSVD.pdf

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