Christ Community Bloomington

Fishack Medical Release Form


Medical and Release Form

Christ Community Church

503 South High Street, Bloomington, IN 47401

Phone (812) 332-0502 Fax (812) 331-8689

I/we give consent for the below named child to attend and participate in all Christ Community Church/Fishack Student Ministries activities for the entire 2022/2023 school year.

I/we authorize an adult, in whose care the minor has been entrusted, to consent to an x-ray examination, anesthetic, medical surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dental licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said or at said hospital. I/we release Christ Community Church or other individuals involved of any liability for accidents incurred during any 2021/2022 school year event.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in the connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.


Name of minor: Age: Birthday:  

Minor's Cell Phone:  Home Phone:  

Address:  

City:  State: Zip:  

Name of Parent(s) or Guardian(s):  Parent/Guardian Cell Phone:  

Parent/Guardian Email:  

Medical Insurance Co.:  Policy #:  Family Doctor:  

Doctor's Phone:  Doctor's Address:  Date of Last Tetanus Shot:  

List any other medical information, conditions, and allergies:

Emergency Contact #1 Name:  Phone: Relation to Minor:  

Emergency Contact #2 Name:  Phone: Relation to Minor:  

Do we have permission to post pictures/videos of this minor on social media?

 

Signer's Relation to Minor:  

Signed Date:

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Fishack Medical Release Form
lock iconUnique Document ID: 4d3c64201218f6d30f5c0cc8c1bca3bedd11759e
Timestamp Audit
July 28, 2022 11:53 am ESTFishack Medical Release Form Uploaded by Lynne Snyder - lynnes@cccbloomington.org IP 68.45.26.188
July 28, 2022 1:37 pm ESTLynne Snyder - lynnes@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
July 28, 2022 1:37 pm ESTMatt Wooden - matthewasherwooden@gmail.com added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
July 28, 2022 1:46 pm ESTLynne Snyder - lynnes@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
July 28, 2022 1:46 pm ESTMatt Wooden - matthewasherwooden@gmail.com added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
December 2, 2022 3:40 pm ESTLynne Snyder - lynnes@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
December 2, 2022 3:40 pm ESTDeonte Moses - dmoses@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
December 15, 2022 11:51 am ESTLynne Snyder - lynnes@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
December 15, 2022 11:51 am ESTDeonte Moses - dmoses@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
December 15, 2022 11:54 am ESTLynne Snyder - lynnes@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188
December 15, 2022 11:54 am ESTDeonte Moses - dmoses@cccbloomington.org added by Lynne Snyder - lynnes@cccbloomington.org as a CC'd Recipient Ip: 68.45.26.188