eMedical Form
HOSPITALIZATION INSURANCE
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COMPANY NAME *
POLICY # *
CERTIFICATE NUMBER
NAME OF INSURED *
IMMUNIZATIONS (please list known immunizations and date received e.g. tetanus 1/6/2012) *
Prescription Medications (include frequency, dosage, etc..)(type "none" if none apply) *
Non-prescription medications that are regularly taken (type "none" if none apply): *
Known Allergies (type "none" if none apply): *
Pre-existing Medical Conditions (e.g. asthma, diabetes, etc. type "none" if none apply) *
Major surgeries, procedures, or other information you may deem important to a healthcare professional (type "none" if none apply): *
Student(s)  Name: *
Student's Date of Birth: *
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Parent/Legal Guardian's Name(s): *
Work Phone #
Cell Phone # *
Home Phone #
Home Address *
Additional Emergency Contacts (Name and number): *
It is expressly understood that my child is to be under the supervision of chaperones and is accountable to them for any misconduct during the trip. I understand that this is a church sponsored event and my child is expected to act accordingly. If my child fails to obey a chaperone and the rules of the event, I understand that I will be responsible for the disciplinary early return expense and means.I do herby release, absolve, indemnify and hold harmless Cowee Baptist Church, its leaders, employees, volunteer staff, organizers, sponsors and supervisors from any and all loss, injury or other damage to us or our child. In case of injury to our child, we hereby waive all claims against the organizers, the sponsors, or any of the supervisors appointed by them. I likewise release from responsibility any person transporting my child to and from activities.To the attending physician or hospital: I certify that the above information is complete and accurate. Any changes or updates will be provided in a timely manner. Permission is hereby granted for you at the discretion of Cowee Baptist Church (its designees and chaperones) to perform whatever care is necessary for the welfare of my child until such time as you are able to reach me/us personally. This release and information contained within is valid for one year from the date of my e-signature. *
Date: *
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