Medical Form 2022-2023
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Child's Name *
Address *
Child's Phone number *
Child's email address *
Does your child have allergies?  If so, what to? *
Does your child suffer from, or has ever experienced, or is being treated for any medical conditions or health complications? *
Please list any major illness the child experienced during last 12 months below *
Does your child wear *
Date of Last tetanus shot *
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DD
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YYYY
Should the child's activities be restricted for any reason? *
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken. *
Father's Name *
Father's Phone number *
Father's email address *
Mother's Name *
Mother's Phone Number *
Mother's Email Address *
Emergency Contact *
Emergency Contact Phone Number *
Physician's Name *
Physician's Phone number *
Medical Insurance *
Policy Number *
I will not hold or attempt to hold Living Stone Christian Church (LSCC here after) or its youth leaders liable for any loss, damage or injury to person or property caused by any act or neglect of other persons during the said event, including travel, or caused in any manner other than willful or negligent act of LSCC and its volunteer workers, and will indemnify and hold LSCC and its youth leaders harmless from any liability for damages or claims against LSCC and its youth leaders arising out of or in any way related to any such loss, damage or injury. I release LSCC, including its trustees, elders, pastors, youth leaders and agents, from the said participant’s physical injury, including death, or illness during the entire event, including travel. I will assume the risk associated therewith, whether known or unknown to the participant at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns. *
Authorization for Treatment: I hereby give permission to the medical personnel selected by LSCC youth leaders to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purpose as outlined under the HIPPA regulation, and to provide or arrange necessary related transportation for the above named person. I verify that the participant is in good health and capable of participating in strenuous activities, and when necessary, will tailor his or her activities within the bounds of his or her physical health. I recognize that any medical treatment that is provided to the participant while attending herein said event will be paid by me or my medical insurance company. *
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