CCP Medical Release

Student Profile Sheet - Medical Release

EMERGENCY MEDICAL RELEASE FOR ALL CHILDREN'S CIRCLE ACTIVITIES

Name of Participant Child*

First Name

Initial

Last Name

Group Policy Name*

Group Policy Number*

Home Phone Number*

In case of medical emergency, I hereby give my permission to permit my child to be transported in private or public vehicles to the nearest hospital and hereby acknowledge and agree that I am responsible for any medical expenses incurred. *

Yes

Parent/Guardian Signature*

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In return for the acceptance of my child’s application and participation, I do for myself, my spouse, my child, and my/their heirs, assigns, personal representatives, and next of kin, hereby release, indemnify and hold harmless SECOND PRESBYTERIAN CHURCH, its agents, successors, assigns, officers, directors, employees, members, and agents, from any and all claims for damages which I or they may have now or in the future as a result of my child’s participation in any SECOND PRESBYTERIAN CHURCH or Children’s Circle Preschool activity. In doing so, I and we agree to assume all risks of loss as may reasonably be expected to arise in connection with my child’s participation in any SECOND PRESBYTERIAN CHURCH or Children’s Circle Preschool activity. Should any part of this release and indemnity be found invalid or unenforceable, the remaining provisions shall remain valid and enforceable.

Parent/Guardian Signature*

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Date/Time*

Allergies

(Please be advised that for the safety of your child, allergy information will be posted in your child’s classroom for all teachers to be aware of and may be in public view at times.)

Hospital Preference

AUTHORIZATION FOR NON-PRESCRIBED MEDICATION OR TREATMENT

A. I give my permission for an authorized representative of Children’s Circle Preschool to administer the following over-the-counter medication(s) or treatment(s):

Bacitracin (to be used for minor cuts and scrapes) Supplied by Children’s Circle Preschool
Sting Kill (to ease the pain of bee sting) Supplied by Children’s Circle Preschool
Benadryl (to relieve symptoms from bee sting, allergies) Supplied by Children’s Circle Preschool
Sunscreen (to protect against sunburn) Supplied by Parent

B. I give my permission for an authorized representative of Children’s Circle to administer the following over-the-counter medication:

Diaper Cream (to be used for diaper rash) Supplied by Parent

C. I will notify the school immediately if there is any change in the use of the medication treatment. (in writing)

Signature*

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Date/Time*