2024 Medical Release Form

Parents please complete this form for your student. All students in Pre-K through 12th grade need to complete this form every year to attend GP Kids/GP Youth events. If you are unsure of whether or not you have submitted this form for 2024 please contact Pastor Madaline or Amanda Longnecker. By submitting this form, you agree that all information listed below is current and accurate to the best of your knowledge.

If emergency services involving medical action or treatment are required and neither parents nor family physician can be contacted for consent, the parents hereby consent to the rendering of such emergency medical opinion of the doctor rendering such service for the student listed below.

Student's Name

First Name

Last Name

Student's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Gender

Student's Date of Birth

YYYY

Student's Age and Grade Level (Pre-K to 12th grade)

Last 4 digits of Student's SSN

Student's Phone Number

(###)

###

####

Parent/Guardian's Phone Number

(###)

###

####

Parent/Guardian's Email

Insurance Coverage

All students are expected to have medical insurance. Your carrier will be billed for medical charges in case of illness or injury. Please list all insurance policy information below including: Group #, Policy#, Insurance Company, Policy Holder's Name, Doctor/Phone.

Emergency Contact

In Case of an emergency, please list the Name, Address, and Phone number of who you would like us to contact. Also, please list their relationship to your student.

Student's Medical Information

Please list any pre-existing medical conditions that your student has and include any medications that they currently take, how often they need to be given and at what dosage.

Student's Allergies

Please list any allergies that your student has. Include seasonal, food, medicinal, animal, plant, etc...

Rules Of Behavior

By submitting this form, the student agrees to adhere to the following rules: No drugs or alcohol are permitted, Student's are required to attend all meetings and stay with a leader at all times unless permitted otherwise by the leader, No tobacco products are permitted, No vaping, No Bullying, No Pranking, No Profanity, No guys in girl's sleeping quarters and vice verse, and all students must follow curfew. Students are expected to be respectful of their leaders and fellow students and obey all rules and listen to leaders directions. Please review these rules with your student. Please indicate below whether or not your student agrees to abide by these rules.

Parent/Guardian Release Statement

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order an injection, anesthesia, or surgery for the subject of this release as deemed necessary. I understand all reasonable safety precautions will be taken at all times by Grace Pointe Assembly of God and its agents during the event/activity. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Grace Pointe Assembly of God, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this release.