Brave Hearts Medical Release Form
Newport Mesa Church- BRAVE HEARTS Group:___________________________
Child’s Name:__________________________________________________________________________
Last First M.I.
Address:______________________________________________________________________________
Street City Zip
Age: _______________________________ Birthdate: ____________________________
Home Phone: ________________________ E- Mail: __________________________________________
Fathers Name: _______________________ Mothers Name: _______________________
Cell Phone: _________________________ Cell Phone: __________________________
Work Phone: ________________________ Work Phone: _________________________
Health Insurance Carrier: __________________________________________________
Group: _____________________________ Policy #_____________________________
Physician’s Name: ____________________Physician’s Phone: ____________________
Is child allergic to any medication? __________________________________________
Is child allergic to any food, animals? ________________________________________
Will child need medication? ________________________________________________
Date of last tetanus shot? __________________________________________________
Are immunizations current? ________________________________________________
The following individuals are permitted to pick up my child:
_________________________________________________________________________________________________
Name Address Phone Relationship
_________________________________________________________________________________________________
Name Address Phone Relationship
Newport Mesa Church and/or Brave Hearts have permission to display photos of my child involved in program activities for communication and publication purposes. YES NO (Circle)
PERMISSION TO PARTICIPATE & MEDICAL RELEASE:
The medical information provided is correct to the best of my knowledge and the above named minor has permission to engage in all prescribed program activities. Except as noted. The undersigned does hereby authorize the directors of Newport Mesa Church or such substitute as they may designate as agent for the undersigned to consent to an x- ray examination, anesthetic, medical, dental, or surgical diagnostic or treatment and hospital care for the minor which is deemed advisable by and to be rendered under the general or special supervision of any physician or surgeon, licensed under the provisions of the Medical Practice act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered in the office of said physician or dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above minor is en-route to and from or involved or participating in any camp program unless revoked in writing by the undersigned and delivered to the Director.
______________________________________ _______________________
Signature Date
_______________________________________________________________________________________________
Relationship to child
