Emergency Medical Form 2025

Dear Parents or Guardians,
In order for your student to participate in student ministries activities, our insurance company requires this form to be on file for every student.

Your name *

Email address *

Students Name *

Birthday *

Address: *

Please include City, State, Postal code

Name of Emergency Contact *

Emergency Contact Phone *

Alternate Emergency Contact *

Alternate Emergency Phone *

Gender *

Male

Female

Is Connect Church authorized to approve medical treatment in an emergency situation? *

Is the participant covered by personal/family medical insurance? *

If yes, name of Insurance Company:

Policy or Group Number

Medical Note *

Please list facts concerning the child’s medical history, including allergies, medication being taken or any physical impairments to which a physician should be alerted.

Preferred Physician *

Preferred Hospital *

Emergency Medical and Participation Agreement

By signing below, the parent/guardian acknowledges and accepts the risks of physical injury associated with participation in the activities. Except for gross negligence on the part of the sponsor, the parent/guardian accepts personal financial responsibility for any bodily or personal injury sustained during the activities. Further, the parent/guardian promises to hold harmless the sponsoring organization and its representatives for any injury related to the activities.

In the event that I, or the alternate emergency contact cannot be reached and the above designated preferred medical practitioner or facility is not available, I consent to the administration of any treatment deemed necessary by another licensed physician at another accessible facility.  Note: This authorization does not cover major surgery unless the medical opinions of two other licensed physicians concur in the necessity of such surgery.

If a dispute over this agreement or any claim for damages arises, the parent/guardian agrees to resolve the matter through a mutually acceptable arbitration process.

Digital Signature *

By typing your name in field below you are considering it your digital signature of consent.

Date of Signature *

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