Medical Release Form

Please fill out one per child.
2025 - 2026
Pleasant View Church

Student Name

Parent(s) Phone

Parent(s) Name(s)

Emergency Name & Phone

Home Address

Age

Birthday

Gender:

School:

Family Doctor:

Doctor's Phone

Medications you are allergic to/other allergic reactions:

Current Medications:

Parent Medical Release: By signing this release form, I hereby grant permission to any Pleasant View Student Ministry Volunteer or any other agent of Pleasant View Church to secure emergency medical treatment for my son/daughter and permission to attending physician, medical facility, and staff in the event of illness or injury to my child and release Pleasant View, its staff, and officers from responsibility in case of accident, illness, or injury.

Parent/Guardian Signature:

Date

Insurance Company Name:

Policy #:

NOTE: This medical release form is effective for one year from the above date. It can be used any time this child is in the care of Pleasant View Church for any reason.

Description

Please fill out this form and click submit.

Medical Release Form

Description

Please Fix the Following