ValleyView Alliance Church - Medical Info & Release Form

Medical Info & Release Form

Please complete this form for the 2018/19 school year so we have accurate information for all SURGE events your youth will attend. Please complete one form for each of your youth.
Youth Name (Last, First, Middle)	*
Age	*
Birthdate xx/xx/xxxx	*
Parent/Guardian Name(s)	*
Home Address	*
City, ZIP	*
Emergency Contacts:
Home Phone	*
Cell Number(s)	*
Medical Conditions and/or Restrictions *
Allergies *
Current Medications *
In the event of a medical emergency or surgical treatment to protect his/her health and welfare while participating in a ValleyView youth event, I authorize and give consent to the administering of such necessary medical and/or surgical treatment. Please type your full name to give consent.	*
Your Email Address	*