Power Lab:  MEDICAL RELEASE FORM

I authorize the staff of Westminster Presbyterian Church Vacation Bible School to obtain emergency medical assistance

  For (child's name)___________________________________ 

  ________________________________________________

If the child's injuries appear to require immediate attention and a parent or guardian cannot be reasonably located I prefer:

           Emergency room preferred: (circle one)

                   Rogue Valley ER               Providence ER

 Provide the name of the Child's Medical Provider to be contacted.  

_______________________      ______________________________

    Child's physician or clinic            Phone number of physician or Clinic

Please list any allergies.  Include medications, foods, etc. 

List any serious medical problems _____________________________________

 ___________________________________     _________    ______________

   Signature of parent or guardian                              Date                    Phone