VBS Medical Release Form - Silverdale Lutheran Church

VBS Medical Release 2022

Family Name
Last
Child 1 Name*
First
Gender*
Birthdate*
Grade Entering in the Fall
Additional information
Please provide any additional information you deem helpful about your child.
Child 2 Name
First
Gender
Birthdate
Grade Entering in the Fall
Additional information
Please provide any additional information you deem helpful about your child.
Child 3 Name
First
Gender
Birthdate
Grade Entering in the Fall
Additional information
Please provide any additional information you deem helpful about your child.
Parent/Guardian Name(s)*
First Last
Best Contact Phone Number*
Alternate Phone Number
Email*
Hospital / Clinic Preference
Physician's Name
First Last
Physician's Phone Number
Insurance Company
Insurance Policy Number
Allergies / Reactions / Special Health Considerations / Dietary Restrictions & important information
Front of insurance card
Max. file size: 100 MB.
Please provide a copy of the front of your insurance card
Back of insurance card
Max. file size: 100 MB.
Please provide a copy of the back of your insurance card.
Consent form*
Consent for emergency medical treatment
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached by Silverdale Lutheran Advisors in the case of an emergency. I agree to pay all medical costs in such emergency treatment.
Covid Waiver*
By checking this box I agree to the Covid Waiver.
SLC will comply with the WA State Governor’s guidelines for employers and faith-based organizations during this time and until further notice. SLC cannot guarantee that you will not become infected with COVID-19 as a result of your presence on campus and assumes no liability with regard to the virus. Any individual, whether staff member, congregant, or group member, who wishes to be present at SLC must:
Self-screen for signs/symptoms before entering the SLC campus,
Wear a face mask that covers the nose and mouth, unless fully vaccinated.
Practice good hygiene, washing hands with soap/water for at least 20 seconds, or use hand sanitizer (at least 60% alcohol content).

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