Medical & Photo Release Form

Medical and Photo Release Form (Sunday School)

Medical Release Form:

Parental Consent and Medical Release Form St. Cross Episcopal Church – Sunday School. I, the undersigned parent or legal guardian of the minor child named below, hereby grant permission for my child to participate in the Sunday School program at St. Cross Episcopal Church. I understand that all reasonable precautions will be taken to ensure the safety and well-being of my child. I voluntarily waive any claim against St. Cross Episcopal Church, its clergy, staff, volunteers, and authorized leaders or sponsors for any liability, loss, or injury incurred during Sunday School activities. In the event of a medical emergency, I authorize and consent to any necessary x-rays, anesthesia, medical or surgical diagnosis or treatment, and hospital care deemed advisable and administered under the supervision of licensed medical personnel and/or hospital staff. This authorization is granted in advance of any specific diagnosis or treatment and is intended to permit medical care in the event of an emergency, as determined by the attending physician’s best judgment. I waive any claim against the church and its approved leaders or sponsors. In case of medical emergency, I hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under, the general or special supervision of any licensed medical personnel on the staff of any licensed hospital. This authorization is given in advance of any specific diagnosis, treatment or hospital care required, but is given to provide authority and power to render care which is deemed advisable in the best judgment of the physician.

Child & Guardian Information

Child's Name(Required)

First Last

Parent/Guardian's Name(Required)

First Last

Relationship

Parent

Legal Guardian

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone(Required)

Cell Phone 2

Emergency & Medical Information

Medical Insurance Company(Required)

Insurance Policy Number

Insurance Phone Number(Required)

Policy Holder's Name(Required)

Policy Holder's Phone Number

Family Physician's Name(Required)

Family Physician's Phone Number(Required)

Any Drug or Food Allergies?(Required)

Any Special Needs?(Required)

Medical Consent

Medical Authorization Agreement(Required)

I authorize and consent to any medical treatment deemed necessary for my child in case of an emergency.

I agree to the above medical authorization.

Parent/Guardian's Full Name(Required)

First Last

(Acts as Digital Signature)

Date of Submission(Required)

Other relative or friend to contact in case of emergency:

First Last Relationship

Phone

Other relative or friend to contact in case of emergency:

First Last Relationship

Phone

Minor Photo Release

General Guidelines: It is recommended that a release be obtained when photographing or videotaping a minor (under 18). Parent or guardian signatures are required; signatures of minors are not sufficient. When images are published, St. Cross will take cautionary steps to provide minimum identifying information and will not use specific street or mailing addresses, email addresses, or phone numbers. If you have questions, please contact St. Cross at 310-376-8989.

Photo Release(Required)

I consent to my child’s images being used.

I do NOT consent to my child’s images being used

Parent/Guardian's Full Name(Required)

First Last

(Acts as Digital Signature)