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Vital Academy Leading the next generation to Worship God, Find Freedom, Discover Purpose and Make a Difference! Monthly Events and Activities Optional Umbrella Covering Strong Support Community Christ-centered Co-op for Pre-K - 12th Grade
 

Medical Release Form

indicates a required answer

In order to avoid delay in treatment, I authorize the adult leader of any Vital Church Academy event or activity to seek medical care for the child(ren) whose names are below. This authority includes any and all treatment deemed medically necessary by a physician or medical professional.

I hereby release any doctor or medical professional, Vital Church, Vital Church Academy and any of its members from any liability arising out of any injury or illness which may occur on or off property of Vital Church in any Vital Church Academy meetings, events, parties, field trips, etc. This authorization shall continue its validity for as long as I am a member of Vital Church Academy.

 
1. *

EMERGENCY CONTACT #1:
2. *

EMERGENCY CONTACT #1 PHONE:
3. *

EMERGENCY CONTACT #2: 
4. *

EMERGENCY CONTACT #2 PHONE:
5. *

INSURANCE:
6. *

POLICY NUMBER:
7. *

GROUP NUMBER:
8. *

EFFECTIVE DATE: 
9. *

POLICY HOLDER'S NAME:
10. *

PHYSICIAN'S NAME: 
11. *

PHYSICIAN'S NUMBER:
12. *

MINOR FIRST AND LAST NAME:
13. *

DATE OF BIRTH:
14. 

MINOR FIRST AND LAST NAME:
15. 

DATE OF BIRTH:
16. 

MINOR FIRST AND LAST NAME:
17. 

DATE OF BIRTH:
18. 

MINOR FIRST AND LAST NAME:
19. 

DATE OF BIRTH:
20. 

MINOR FIRST AND LAST NAME:
21. 

DATE OF BIRTH:
22. 

MINOR FIRST AND LAST NAME:
23. 

DATE OF BIRTH:
24. 

MINOR FIRST AND LAST NAME:
25. 

DATE OF BIRTH:
26. 

MINOR FIRST AND LAST NAME:
27. 

DATE OF BIRTH:
28. *

PARENT/GUARDIAN SIGNATURE:

This electronic signature serves as my official signature.