Medical Release Forms | JourneyConnect.org

Campus

Student's First Name

Student's Last Name

Student's Date of Birth

Student's Email

Student Cell Phone

Student's Address

Mother's First Name

Mother's Last Name

Mother's Cell Phone

Mother's Home Phone

Mother's Work Phone

Father's First Name

Father's Last Name

Father's Cell Phone

Father's Home Phone

Father's Work Phone

First Name

Last Name

Relationship to Child

Cell Phone

Home Phone

Work Phone

Family Physician

Health Insurance Company

Policy #

Current Medical Conditions:

Asthma Kidney Trouble Heart Diabetes Abnormal Blood Pressure Dizziness Hay Fever Epilepsy Stomach/Digestive Trouble

Current Medical Conditions: Other

Immunizations:

Tetanus Polio Booster Measles Mumps

Allergies:

Penicillin Insect Sting/Bites Poison Oak/Ivy/Sumac

Allergies: Food

Allergies: Other Medications

Previous Operations/Illnesses

Current Medications/Dosage

Special Diet

Additional Information

My permission is granted for Journey Church staff member, adult chaperone, or camp sponsor while at any function sponsored by the church, to obtain necessary medical attention in case of sickness/injury for your child listed above. My permission is granted for Journey Church staff member, adult chaperone, or camp sponsor while at any function sponsored by the church, to transport to and from the church, Journey Church, from September 2024-August 2025. I, the undersigned, do hereby release, remiss, or forever discharge all staff members/adult chaperones/sponsors of Journey Church from any and all claims, demands, actions, or cause of action, past, present, or future arising out of any damage or injury while participating in an event.

Check here if you affirm the statement above.

Please Type Your Full Name As a Signature

Date

I give permission to Journey Church to photograph my child at any function sponsored by the church. I give permission to copyright, use and publish the photographs for any lawful purpose, including newspaper articles, church publications, and church website.

Please Type Your Full Name As a Signature

Date

Check here if you do not want your child's picture used for any purpose.

Work Entry

Journey Students Medical Release

Medical Information and Release Form

Parent Information

Emergency Contact

Insurance Information

Medical History