Student Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Student Phone *

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Parent Name *

First Name

Last Name

Parent Phone *

(###)

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Medical Release *

BridgePointe Student Medical Release* I, the undersigned parent or guardian of the minor named below, do hereby authorize adult workers with the youth of the BridgePointe Christian Church to consent to any examination, x-ray, anesthetic, medical, or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physical or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named below, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for rendering such services.

I Agree