Medical Release Form 2023
Connect Youth Ministries

Insurance Company and Policy needed

Expires after the year 2023 -- Renew in 2024

Any questions, email Austin at austin@cdanaz.org or call the office at (208) 667-3543
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Email *
Student Information
Please fill out each required section with information concerning your student.
Student Name *
First and Last
Student Age *
Student Birthday *
MM
/
DD
/
YYYY
Student Address *
Medical Information
Please list any allergies, medications, or medical conditions/needs (answer NA if not applicable): *
Please give any special direction for any medication (time of day and frequency, amount, etc.) or special instructions per medical treatment (answer NA if not applicable): *
Insurance Company & Policy
Emergency Contact Info
Primary person to contact in case of emergency: *
Relationship to student: *
Primary Emergency Contact
Cell Phone *
Primary Emergency Contact
Secondary Phone *
Primary Emergency Contact
Secondary person to contact in case of emergency:
Relationship to student: *
Secondary Emergency Contact
Cell Phone
Secondary Emergency Contact
Secondary Phone
Secondary Emergency Contact
I (we) the undersigned parent, parents, or legal guardian of the above named student hereby authorize and consent to any medical examination or treatment of said party. It is understood 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 to render care which the physician in the exercise of their best judgement may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also waive, release and forever discharge any and all rights and claims for damages which the above mentioned may have or which may hereafter occur to them, against Connect Youth Ministries, Coeur d'Alene Church of the Nazarene, Hayden True North Church of the Nazarene, and/or Post Falls Church of the Nazarene or their officers, representatives and successors for any and all loss or damage which may be sustained and suffered by them in connection with their association and involvement in and/or arising out of their traveling to participation in and returning from any event sponsored by Connect Youth Ministries, Coeur d'Alene Church of the Nazarene, Hayden True North Church of the Nazarene, and/or Post Falls Church of the Nazarene.
Signature of Parent(s) or Legal Guardian *
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