Name: _____________________________________________________ Age: _________
Phone: _____________________________________________ City: ___________________
Address: ____________________________________________ State: _____ Zip: ________
Notify In Emergency: __________________________________ Phone: ________________
Insurance Company: _________________________________ Policy #: ________________
Family Physician: _____________________________________ Phone: _______________

Past Medical History
Please note any allergies: Food __________________ Penicillin or other drugs __________________
Insect bites/stings _______ Poison Sumac, Oak, Ivy ______  Other: ________________________
Please list any medications you are taking: ______________________________________
(If you need more space, list items at the bottom of the page.)

My permission is granted for the church minister, church official, or any other chaperone in charge to obtain necessary medical attention in case of sickness or injury to my child. Also, I understand that as a participant, my child may be photographed or videotaped during normal church activities and these photos/videos may be used in promotional material.
I, the undersigned, do hereby verify that the above information is correct.  I do hereby release and forever discharge all sponsors and Four Seasons Community Church, Edgewood, KY, from any and all claims, demands, actions, or cause of action, past, present or future arising out of any damage or injury while employed or participating in Four Seasons Community Church, Edgewood, KY, activities.
 
Parent/Guardian Signature_______________________________________________________
 
Dated this _______ day of _______________, __________ State of ____________ County of _______     
On this the _______ day of _____________, _______, personally appeared before me _______________
Personally known by me, and in my presence executed the within and foregoing permission and release form. Witness my hand and official seal this __________ day of _____________________, ____________.
 
Notary Public ___________________________  My commission expires ___________________________