Youth Ministry Medical and Liability Release

STUDENT'S NAME ______________________________ BIRTHDATE ___________ AGE _____
ADDRESS ________________________________ CITY _________________ ZIP _________
EMAIL ____________________________________ GRADE LEVEL __________
PARENTS'/GUARDIAN NAMES ____________________________________________________
HOME PHONE ________________ WORK PHONE ________________ CELL _______________

Local emergency contact (in case parents are out of town)
NAME _______________________________ PHONE ______________________

HEALTH HISTORY (please explain any conditions we should be aware of):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies (insect stings, medications, food, etc.):
____________________________________________________________________________________________________________________________________________________________

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Posted: March 1, 2013
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