RELEASE FORMS

We require that all students who participate in EWYG events fill out a medical release form, and also read and sign a Guideline sheet. We need to keep everyone safe in the event of an emergency, and while we do not expect everyone to be a baptized believer before they participate, we do expect them to behave in accordance with what we have deemed appropriate behavior for people their age. We have also provided our expectations for all adults who wish to chaperone our events.

Medical Release Form

Please fill out the following form in order to participate in EWYG activities.

I, the undersigned, parent/guardian of

First Name of Minor

Last Name of Minor

a minor, do hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the supervision of any licensed physician/surgeon, whether such accredited treatment is rendered at the office of the physician or at YOUR HOSPITAL.

I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which aforementioned physician/surgeon in the exercise of his/her judgment may deem advisable.

Your Signature

Street Address

City

Region/State/Province

Postal / Zip code

Minor's Date of Birth

Date of last tetanus shot

Blood Type

Allergies

Special medications or medical problems:

Family physician and phone

Medical insurance carrier

Policy number, agent

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!