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Microsoft word - ng - medical release 2014.doc


Dear Parent or Guardian,
Please complete a separate release for each minor that will be participating in church activities. Please
print all information.
Student Personal Information:

Parent/Legal Guardian Information:

Insurance Information:

Person other than parents to notify in case of emergency:
Personal Permission and Medical Information:
In the event of an emergency where medical treatment is required, I give my permission to the staff or
sponsor to obtain the services of a licensed physician. Please attempt to notify me immediately concerning
any such emergency. I will check all of the common, over-the-counter medications that my child may take.
Are there any medications or foods that your child is allergic to?


Please list prescription medications that your child must take while at the event.


Name of Medication

Please check any chronic health situations we need to be aware of:


I have read the above statements and the policies that are attached. I agree with their statements.
**ONLY SIGN BELOW IN THE PRESENCE OF A NOTARY**
Parent/Guardian


Notary signature

Commission Expires
Health Care Policy
1. All students traveling with Pure Heart will have a notarized medical information and release form 2. Pure Heart Christian Fellowship will staff a medical advisor on events that require students to be away from home for more than 25 hours. This medical advisor’s certification and license will be current, and will be referred to as nurse in this document. 3. Parents will be responsible for making the nurse aware of any medical conditions or medications 4. Medications in the original container with physician’s directions and over-the-counter medications approved by the parent on the medical form will be dispensed by the nurse. 5. In event of a medical emergency, 911 will be called immediately and every attempt will be made 6. In the event of an illness, injury, or other medical emergency, the parent/guardian will be contacted immediately. In non-emergency situations, care will be given by the nurse. 7. It is the parent’s responsibility to provide medical insurance for the student. It will be the parent’s responsibility to assume all expenses for any medical treatment. 8. All visits to the nurse will be logged with date, time, reason and treatment. This log will be kept 9. Pure Heart Christian Fellowship will in no way hold the nurse, or any other adult liable for any Discipline Policy
1. The children’s pastor has the authority and responsibility to create a positive and safe environment 2. All students traveling with Pure Heart Christian Fellowship will conduct themselves in a civil manner, abiding by all rules and regulations set forth for the event. All students will show respect for all people, God, adults and all peers. 3. Parents will assume the responsibility for student’s behavior. Any student not conducting themselves in an appropriate way, which endangers them or others, will be sent home at the parent’s expense, as deemed necessary by the student’s pastor. 4. The student’s pastor has all authority to use appropriate discipline measures suitable for the behavior. These measures may result in lost privileges, phone calls home or possibly being sent home. 5. Property damages will be repaired and/or replaced at the parent’s expense. I have read the medical release and discussed the discipline policy with my child. We understand the consequences of misbehavior and accept full responsibility for the choices that will be made while attending the above mentioned event. Parent Signature

Source: http://pureheart.org/wp-content/uploads/pdf/Medical%20Release%202014.pdf

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YES (Y) OR NO (N). All responses are kept confidential. Chief Complaint (reason for your visit):___________________Clicking or Popping of the jaw joint,pain near ear, difficulty_____________________________________________________opening mouth,grind or clech teeth?………………. Are you in good Health?………………………………. Sinus or nasal problems?……………………

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