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Office use

For ONE Community Church youth activities January 1 to December 31, 2011

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COUNSELOR NAME HOME PHONE CELL PHONE
_____________________________ ___________________________
ADDRESS EMAIL
__________________ _______ _________ _______________
CITY STATE ZIP CODE BIRTHDATE

____________________________________________________ ______________________ ______________________


SPOUSE NAME (if applicable) SPOUSE CELL ANNIVERSARY

OTHER INFORMATION
_____________________________
PLACE OF WORK Draw Something:
_____________________________
POSITION
______________ _____________
FAVORITE SNACK FOODS FAVORITE COLOR

SHIRT SIZE (circle) S M L XL XXL

Emergency Contact :_________________________________ _____________________ __________________


NAME PHONE RELATIONSHIP

LIABILITY RELEASE
I, _____________________________, do release ONE Community Church, its employees and volunteer
staff from any personal liability for injury, illness or death as a result of participation in youth activities sponsored
by ONE Community Church. I understand that involvement in youth activities may include hazardous activities
such as skiing, snowboarding, various athletic involvement, water sports, hiking/climbing, night games, field games,
travel in vehicles, physical exertion and other such participation.
I authorize consent for X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment
and hospital care, to be rendered under the general or special supervision and on the advice of any physician or
dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or
medical clinic, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital or
medical clinic.
The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such
medical and dental services rendered.
Should it be necessary for me to return home due to medical reasons or otherwise, the undersigned shall
assume all transportation costs.
Signature 1 of 2

_____________________________________________ ____________________________
SIGNATURE DATE

COMPLETE OTHER SIDE


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Office Use

Please fill in all blanks. Where necessary write “NONE”.

INSURANCE INFORMATION
INSURANCE:  YES  NO
__________________________________ ______________________
INSURANCE COMPANY POLICY NUMBER
_____________________ _________________ __________________
PHYSICIAN PHONE NUMBER AFTER HOURS PHONE
__________________________________________________________
PHYSICIAN’S ADDRESS

MEDICAL HISTORY
______________________________________ _________________
DRUG ALLERGIES DATE OF LAST TETANUS SHOT
__________________________________________________________
OTHER ALLERGIES

________________________________________
OTHER MEDICAL PROBLEMS:
__________________________________________________________

MEDICATION:
______________________________ __________________________
NAME OF MEDICATION #1 DOSAGE & FREQUENCY
__________________________________________________________
REASON FOR MEDICATION #1
______________________________ __________________________
NAME OF MEDICATION #2 DOSAGE & FREQUENCY
__________________________________________________________
REASON FOR MEDICATION #2
______________________________ __________________________
NAME OF MEDICATION #3 DOSAGE & FREQUENCY
__________________________________________________________
REASON FOR MEDICATION #3

Hospital Preference:_____________________________________________________________________________

ADDITIONAL INFORMATION IMPORTANT FOR YOUR MEDICAL/PHYSICAL CARE:


__________________________________________________________
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