Medical Release for YFM Events and Participant Information 2017-2018

St. David’s Episcopal Church

Medical Release for YFM Events and Participant Information 2017-2018

Return to:Allen Bower, Director of Youth & Family Min.•2410 Glenview Rd.•Glenview, IL 60025

Participant Name (please print) /
Male/Female/Non-binary
Date of Birth
Grade in School 2017-2018
Address
City, State, Zip Code
Home Phone #
Youth Cell Phone # / I may receive
text messages
Y N
Youth Email /

• I would like to receive event info by e-mail.

Parent/Guardian Email /

• I would like to receive event info by e-mail.

Health Insurance Company
Policy #
Insured’s name
Youth relationship to insured
Family Physician
Physician Phone
daytime / after hours
Emergency Contact / Name (Please print) / Work Phone # / Cell Phone #
Parent/Guardian
Parent/Guardian
Emergency Contact if parent cannot be reached. Relationship?
Special Medical Concerns (that might limit participation or be important in an emergency)
Dietary Restrictions
Vegetarian / ______Yes _____ No
Allergies

Please attach additional page if needed. This is confidential and the more we know the better we may tend to your youth during events and trips.

The following is a list of medications youth participant will need to take while attending events: (please attach list if additional room is needed.)

Medications to be administered / Dosage / Times

•All prescription medication must be properly labeled in its original pharmacy container.

• Over the counter medication should be labeled with participant name on container.

Permission to receive OTC medications: I give my permission for my child to receive over the counter medications from adult staff at events, such as Tylenol, ibuprofen, cough drops, Mylanta etc.

Parent/Guardian Signature ______Date ______

Parental Consent: I give full permission for my child to attend St. David’s events, including but not limited to: Fall Retreat, weekly youth meetings, local outings, local mission events, Mission Trips, 30 Hour Famine and other events named here: _______

Photo/Video Publicity Release Statement YES NO

I give my permission for photographs or video footage of my child to be used by St. David’s Episcopal Church for promotional purposes. (Brochures, website photos, promotional videos, etc.) No names are used on website photos or in publicity.

Participant Roster YES NO

I give my permission for my child’s address/phone number/email to be included on a participant roster of the event (for use of participants only)

Transportation Release: I give full permission for my child to be transported to youth activities in conjunction with the above mentioned events, away from our meeting site, riding in approved vehicles, with approved drivers at St. David’s, and to attend and participate in activities off site of our main program.

Parent/Guardian Signature ______Date ______

• (847) 724-1341.office•

(248)818-0837.cell