Medical Authorization and Media Release Every CityReacher, student and adult, must complete and sign this form. Upon arrival to #CRMadison, Group Leaders will turn in all forms at the registration table to be turned into the CityReach nurse. It is of the utmost importance that these forms are completed and turned in upon arrival to CityReach, so please plan accordingly to have these forms completed. Name:_________________________________ Age:____ Grade:____ Male Female Address:_____________________________________________________________________ City:_____________________ State:____ Zip:_________ Sponsor’s Name:_________________________ Pastor’s Name:________________________ Attending Church Name:_________________________________________________________ In case of emergency, notify: Name of Parent / Gaurdian:_______________________________________________________ Address:______________________________________________________________________ City:_____________________ State:____ Zip:_________ Primary Phone:_______________________ Circle one: Home / Cell / Work Secondary Phone:_____________________ Circle one: Home / Cell / Work Secondary emergency contact: Name:___________________________________ Relation:____________________________ Address:______________________________________________________________________ City:_____________________ State:____ Zip:_________ Primary Phone:_______________________ Circle one: Home / Cell / Work Secondary Phone:_____________________ Circle one: Home / Cell / Work
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Medical Authorization and Media ReleaseEvery CityReacher, student and adult, must complete and sign this form. Upon arrival to #CRMadison, Group Leaders will
turn in all forms at the registration table to be turned into the CityReach nurse. It is of the utmost importance that these forms are completed and turned in upon arrival to CityReach, so please plan accordingly to have these forms completed.
Name:_________________________________ Age:____ Grade:____ Male Female
Address:_____________________________________________________________________
City:_____________________ State:____ Zip:_________
Sponsor’s Name:_________________________ Pastor’s Name:________________________
Attending Church Name:_________________________________________________________
In case of emergency, notify:Name of Parent / Gaurdian:_______________________________________________________
Address:______________________________________________________________________
City:_____________________ State:____ Zip:_________
Primary Phone:_______________________ Circle one: Home / Cell / Work
Secondary Phone:_____________________ Circle one: Home / Cell / Work
Secondary emergency contact:Name:___________________________________ Relation:____________________________
Address:______________________________________________________________________
City:_____________________ State:____ Zip:_________
Primary Phone:_______________________ Circle one: Home / Cell / Work
Secondary Phone:_____________________ Circle one: Home / Cell / Work
Major medical history (check all that apply):
Asthma Diabetes Kidney Trouble Heart Condition:_________________________
Dizziness Bronchitis Sinusitis Concussion Other:_________________________
Please list any allergies:
Consent for Medical Treatment and Media ReleaseI give full permission for the above to attend CityReach and to take part in all activities. My child will not attend if he/she has been exposed to a contagious disease of if he/she is not in good physical condition. I do not hold CityReach Personnel and/or Sponsors responsible or any accident or illness; and if necessary, authorize CityReach Personnel and/or Sponsors to take my child to a physician or hospital. I also give my full consent for the doctor selected to render professional services to my child, if he/she becomes ill or is involved in an accident. As a parent/legal gaurdian, I give my permission for the above to be photographed and/or filmed during CityReach for the purpose of publications, multimedia, or website.
Charges for InsuranceCompany Name:_______________________________________ Policy Number:_________________
Address:________________________________ City:_____________________ State:____Zip:_______
Phone:_________________________________
Have doctor bill me:Company Name:________________________________________________________________
Address:______________________________________________________________________
City:_____________________ State:____ Zip:_________
___________________________________________ __________________Parent/Gaurdian Signature Date
Has CityReacher recently been under a doctor’s care? (explain):
Will the camper be taking medication while at CityReach? Yes NoMedicine:___________________________ Dosage:_____________ Time of Day:__________
Medicine:___________________________ Dosage:_____________ Time of Day:__________
Permission to administer (check all that apply):
Tylenol Ibuprofen Benadryl Antacids Cold Medication Antibiotic Cream
___________________________________________ __________________CiyReacher Signature Date
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