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News & Resources >  This Sunday at Brick >  Youth Medical Release > 

Youth Medical Release

Student's Name
First*
Last*
Birthday*
Parent/Guardian Name
First*
Last*
Primary Phone Number*
Alternate Phone Number*
Parent Email Address*
Emergency Contact Name*
Emergency Contact Number*
Permission Agreement
I,*
hereby grant my son/daughter*
a minor child, permission to participate in The Brick Church Youth Group. I will not hold The Brick Presbyterian Church, their staffs, Sessions, or the approved leaders or sponsors, liable for any accident or injury occurring during scheduled Youth Group events. I hereby grant permission to the adult supervisors and leaders of this group to make medical decisions with respect to said minor child in the event of an accident or injury when parental consent shall be unavailable or when circumstance
Signature
Enter initials to sign*
Medical Information
Does your child have any allergies?
 Yes  No
If yes, please explain
Does your child take any medications?
 Yes  No
If yes, please list medications and conditions for which they are taken
Additional information about the participant’s medical history
Information regarding your medical insurance
Name of Insurance Company*
Policy Number*
Phone numbers for verification by emergency room staff
Expiration Date (if any)
Insurance Company Address
Street
City
State
Zip
Employer Name
Name of Policy Holder

    
62 East Ninety-second Street, New York, NY 10128-1398 • Tel: 212-289-4400 • Fax: 212-996-7078
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