Medical Release - Easley Presbyterian Church

Name*

First

Last

Birth Date*

Street Address*

City*

Zip Code*

Email*

Parent/Guardian Name*

First

Last

Parent/Guardian Phone*

Parent/Guardian Name(2)

First

Last

Parent/Guardian Phone(2)

Insurance Carrier*

When you hit submit, you will be directed to our PayPal page where you may pay by credit card or use your PayPal account. If you prefer to pay by check, just exit the page. Make checks payable to EPC.

Insurance Phone*

Family Doctor*

Doctor's Phone*

Please list any allergies or medical concerns

Check any that apply:

Contacts?

Glasses?

Braces?

Please list current medications

Emergency Contact other than parent/guardian:

Emergency Contact Name

First

Last

Emergency Contact Phone

Relationship

If Minor, in case of emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give permission to the medical professionals selected by the group leader to treat my child as necessary. By electronically submitting this form, I affirm that the above information is correct.

This form is valid for one year from submission date.