2020 St. Andrew UMC Student Release and Waiver

Student 1 Name

Student 2 Name

Student 3 Name

Student 4 Name

Address

Parent/Guardian Name(s)

Insurance Information

Insurance Company

Insurance Number

Physician Name

Emergency Contact

Your Emergency Contact Phone

Name #2 Emergency Contact

Phone #2 Emergency Contact

Medical Concerns

Allergies (list severity) or medical concerns we should be aware of

Permissions

I authorize St. Andrew UMC and its staff and volunteers to seek medical care on my child's behalf if I cannot be reached within any medically necessary time-frame. Please initial here to give your permission.

I give permission for the staff and volunteers (21 years of age or older) to transport my child as is necessary for the sponsored event/s. Please initial here to give your permission.

Please type your full name here as an electronic signature

Today's date

Description

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2020 St. Andrew UMC Student Release and Waiver

Description

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