Please take a few moments and fill out the Medical Release Form below. If you have more than one child you will need to complete a new form for each child. Once you are finished click the submit button. Fields with a * are required. Thank you.

Child's Name *
Child's Name
Birthdate *
Birthdate
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Mobile Number *
Parent/Guardian Mobile Number
Home Address *
Home Address
Second Parent/Guardian or Emergency Contact *
Second Parent/Guardian or Emergency Contact
Home Address
Home Address
Business Address
Business Address
Mobile Number *
Mobile Number
Health History (Check all that apply)
Date of last physical examination
Date of last physical examination
Date of last tetanus shot
Date of last tetanus shot
Insurance information- it is important that this be completed in case of an emergency. In case of an emergency the parent or guardian will be contacted. In the event the parent or guardian cannot be reached we will call the emergency contact number. If any changes in the health of the stated child occurs after the completion of this form, please inform the necessary changes to the Family Ministries Pastor at City Church.
AUTHORIZATION OF CONSENT TO TREATMENT OF MINOR *
We, the undersigned parent(s) or guardians of stated child, a minor, do hereby authorized adult workers with children and youth of City Church Chattanooga as agent(s) for the undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act of the medical staff of a licensed hospital, whether such a diagnose or treatment is rendered at the office of said physician or at said hospital. I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this form.
Parent/Guardian Signature *
Parent/Guardian Signature
Today's Date *
Today's Date