In the case of a medical emergency and I cannot be contacted, I give my permission for Occupied Church or a sponsor/worker of Occupied Church to act in my place and make decisions concerning medical treatment for my child

Child's Name

First Name

Last Name

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Parent(s) Work Phone

(###)

###

####

Parent Name(s)

First Name

Last Name

Name of Physician

Phone

Insurance Carrier/Policy Name or Number

Important Medical Information

(Allergies, Alerts, etc.)

I fully understand that my child will be traveling and participating in all activities at his/her own risk. I fully understand that neither Occupied Church nor its sponsors and/or workers will be held responsible for any accidents or injuries.

I understand

Medical Release Form

In the case of a medical emergency and I cannot be contacted, I give my permission for Occupied Church or a sponsor/worker of Occupied Church to act in my place and make decisions concerning medical treatment for my child

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