2025 Medical Release Form

This form is for Teens For Christ, PO Box 920, Hudson, WI 54016. It is effective for any Teens For Christ event in which my child participates from January 1, 2025 - December 31, 2025.

Submitting this form indicates my agreement to have this form signed electronically.

Participant Information

Participant's First Name

Participant's Last Name

Birthdate

Gender

Male

Female

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Parent or Legal Guardian Information - 1

First Name

Last Name

Relationship

Phone Number

Parent or Legal Guardian Information - 2

First Name

Last Name

Relationship

Phone Number

If parent(s)/legal guardian cannot be reached in an emergency, contact:

First Contact - First Name

First Contact - Last Name

Phone Number

Relationship

Second Contact - First Name

Second Contact - Last Name

Phone Number

Relationship

In case of sickness or accident, please complete the following:

Hospital Insurance Company

Policy #

Group #

Any known allergies to medicines, food, bee stings, etc.?

Any medical conditions such as diabetes, asthma, heart problems, depression ADD, ADHD, or any physical exercise limitations? If yes, please explain.

List any medications your child is taking and the reason for the medication.

Check any/all options of over the counter medications your child has permission to take:

Tylenol or Ibuprofen for headaches, pain, or fever

Benadryl, calamine, or caladryl lotions for insect bites/skin irritations

Antacids (tums or Pepto Bismal) for upset stomach

Antibiotic cream such as bacitracin for cuts and scrapes

None of the above (this will nullify any other selected option)

Anything you wish to tell us about medications?

I am the participant's parent or legal guardian and hereby give my permission to medical personnel wiht proper credentials to give emergency medical treatment and care to the above named participant.