Saint Luke UMC - After School Permission/Release Form

St. Luke Afterschool Program
Medical & Permission Release Form

Child's First Name

Child's Last Name

Child's Birthdate

To: St. Luke Afterschool Care Program, St. Luke UMC, Sanford, NC and those in charge of these students, Our/My child, named above, which has been enrolled in your program has our/my permission to attend and participate in all activities, scheduled and unscheduled in and out of the regular meeting place.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Family Physician First Name

Family Physician Last Name

Family Physcian Phone Number

Insurance Company

Insurance Group #

Insurance Policy #

Known Allergies

Any past medical history that we need to be aware of:

Any current daily medications:

I give my permission for the director or staff in charge to obtain necessary medical attention in case of sickness or injury to our/my child if I cannot be reached. I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge all sponsors and employees of St. Luke Afterschool Care Program and St. Luke United Methodist Church from any and all claims, demands, actions or cause of action, past and present, or future arising out of damage or injury while participating in our activities.

Date Input

Signature

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St. Luke Afterschool ProgramMedical & Permission Release Form

St. Luke Afterschool Program
Medical & Permission Release Form