In order to attend any out of house events or field trips with SCC this form must be completed and on file within the past year.
SCC Medical Release/Liability Waiver/Insurance Form

Student's First Name:

Student's Middle Name:

Student's Last Name:

Address-street: (required)

City, state, zip: (required)

Home Phone:

Student's Cell:

Student's Email:

Parent's Name:

Parent's Phone:

Parent's Email:

2nd Parent's Name:

2nd Parent's Phone:

2nd Parent's Email:

Student's Birthdate:

Student's Age (required)

Student's Next Grade (required)

I give permission to use my student's pictures on church affiliated social media:

Allergies (if any)

Emergency Contact:

Emergency Contact's Phone:

Ralationship to Student:

Health Insurance Company:

Policy Number:

Policy Holder:

Doctor's Name:

Doctor's Phone:

Medications currently taking:

(All prescriptions medications must be in original bottles, labeled with patient name, doctor's name, time and dosage to be taken- Over the counter medications must be in original container.)

My student may be given Tylenol or Advil if needed.

Date of Last Tetanus shot:

In case of emergency: If I am unable to be reached, I give permission to the Smyser Christian Church, by its representatives to hospitalize, secure treatment for, and to order anesthesia or surgery for my child named above. I further agree to be responsible for any and all bills incurred for such treatment.
I, hereby, give full authority to the representatives of Smyser to use his/her discretion in determining if such medical treatment is necessary, and I release Smyser Christian Church (i.e. representative, leadership, and congregation) from any and all responsibility for the results of that determination.
I further release Smyser Christian Church and it's representatives from any responsibility other than supervision and care of my child.

Today's Date:

Please write your signature in the box below