MEDICAL

RELEASE FORM
Vacation Bible School, The Rock Church of St. Louis, 2013
Date:____________________________
Form Completed by (print):_________________________________________
Name of Child: ___________________________________________________Age:_______ Grade (2013-14 school year):________
Parent/Legal Guardian (print):________________________________________________
Parent/Legal Guardian (signature):___________________________________________
Address:__________________________________________________________________________
City:____________________________________________ Zip: _____________________________
Emergency Phone #s:
Home:________________________________Cell:_________________________________Work:_____________________________________
Best # to reach you during 9:00-12:00 daily (check all that apply): Home Cell Work
If parent/legal guardian cannot be reached in the event of an emergency, contact:
Name:_______________________________________________________ Phone:_________________________________
Health Insurance Company:__________________________________________Policy or Group Number:_____________________
Customer Service Phone:_______________________________________________________
Please list any (1) allergies or (2) allergic reactions child has and any (3) medications child is taking:
___________________________________________________________________________________________________________________________
Does you child have an medical or special needs, including medications currently being used:
No__________ Yes____________ If yes, please explain:____________________________________________________________________
Doctors Name________________________________________________ Phone #:_______________________________________________
Dentists Name________________________________________________ Phone #:_______________________________________________
Date of last tetanus shot:____________________________________ Birth date:_____________________________________________
MEDICAL RELEASE
I,______________________________________, having legal custody of _____________________________, who resides
with me at the above address, entrust his/her care to the adults responsible for any church-sponsored
activity, such as Vacation Bible School, of The Rock Church of Saint Louis, Brentwood, Missouri.
AUTHORIZATION FOR EMERGENCY CARE
In the event of an emergency, or if I cannot be reached, I hereby authorize adult volunteers of THE ROCK
CHURCH OF ST. LOUIS, as agent(s), to provide any medical treatment or surgical care care deemed advisable
by any accredited physician(s) or surgeon in an approved emergency clinic or hospital selected by
THE ROCK CHURCH OF ST. LOUIS leaders deemed necessary for the health and/or safety of my child.
I further release from any liability THE ROCK CHURCH OF ST. LOUIS, any of its ministry or leaders in the
event of an accident en route, during and returning from the above mentioned event. The agreement does
not apply to claims for intentional misconduct or gross negligence.
I understand that I will be ainancially responsible for the cost of any medical treatment and ambulance or
other transportation expense for my child.
Although I recognize that circumstances such as time and distance may affect the choice of medical facility,
I prefer that my child be treated at the following hospital:______________________________________________.
Signature of Parent or Legal Guardian

Note: Please bring this form with you the 1st day of VBS
9125 Manchester Road, Brentwood, MO 63144
Phone 314-968-0600 | Fax 314-962-8886
www.theROCKstl.com

Date