Christ Church Assembly of God



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Childcare Medical Release Form

I hereby give permission for any and all medical attention necessary to be administered to my child (name) _________________________________ in the event of accident, injury, sickness, etc., while they are cared for on Victory Family Church property, until such time as I may be contacted.

If neither of the person(s) designated below can be contacted, I give permission for treatment of my child as may be required and determined by the appropriate health care professional who is present.

I hereby assume responsibility for payment of such treatment and have provided my child’s insurance information below.

I further understand that:

• My child may not be dropped off at the church any earlier that 5:30 PM for Life Group meetings on the designated Life Group Sundays.

• My child must be picked up from Victory Family Church no later than 8:15 PM on Life Group Nights.

My name: ____________________________________________________________________

Phone(H):________________(W):_________________(Cell)___________________________

My home address:_____________________________________________________________

City:_________________________________State:_______________Zip:_________________

I the parent will be off the church premises at the following location _______________________

In case I cannot be reached, either of the following is designated:

Name:___________________________Phone: ______________________________________

Name: __________________________ Phone: ______________________________________

My insurance policy number is:___________________________________________________

My child’s physician:____________________________________________________________

Physician’s Phone:_____________________ Address:________________________________

Known allergies or medical conditions of child:_______________________________________

Medications child takes: ________________________________________________________

Name of Life Group You Are Participating In: _________________________________

Phone Number of Life Group Home: ________________________________________

Parent’s name (print): __________________________________________________________

Signature (parent): _____________________________________________________________

Today’s Date: ________________________________________________________________

Please return to the Victory Family Church office upon completion. No child will be accepted into childcare at Victory Family Church without this completed form.

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