Spring Break Service Trip 20232023 Spring Break Trip Medical Release and Permission FormStudent Medical Release for the 2023 Spring Break trip to St. LouisStudent InformationStudent Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Year in School(Required)9th10th11th12thSex(Required)MaleFemaleHome Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Phone NumberContact InformationMother Name First Last Mother PhoneFather Name First Last Father PhoneParent Email(Required) Emergency Contact Name(Required) First Last Emergency Contact Relation(Required)Emergency Contact Phone(Required)Medical HistoryLast Tetanus Shot(Required)Month/YearDoes student have... Food, medication, or environmental allergies. Heart condition. Learning or behavior disability.If "yes" please explain in accompanying box.Is student subject to... Fainting. Sleep walking. Upset stomach. Motion sickness. Other.If "yes" please explain in accompanying box.Any other medical, nutritional, social, or behavior concerns for the event?Medication(Required)If necessary, you have permission to give my youth: Robitussin (cough medicine) Acetaminophen (Tylenol) Diphenhydramine (Benadryl) Topical Antibiotic (Polysporin) Pepto Bismal Dramamine (motion sickness) Rolaids, Mylanta (antacid) Ibuprofen (Advil, Motrin) Solarcaine Spray/Lotion Please consult me before offering any medication.Consent(Required)This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. I consent.Medical InsuranceAccepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.Please provide a picture of your medical card.Δ