inolacc.org - ICC Medical Release Form

2026 - 2027 | ICC Medical Release Form

Student Information

First Name

Last Name

Date of Birth

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Parent / Legal Guardian Contact

First Name

Last Name

Relationship to Student

Phone Number

Email

First Name

Last Name

Relationship to Student

Phone Number

Emergency Contact Information

(Please list someone other than the parents/guardians listed above.)

Emergency contact Name

Relationship to Student

Phone Number

Authorized Pickup

Who is authorized to pick up your student?

Medical Information

Preferred Hospital

List of known allergies (food, environmental, medications, etc.)

List of medications the student may need to take during the after-school program. (Note: W.A.S.P. leaders cannot administor medication.)

Photo & Video Permission

Photo and Video Permission

I give permission for my child's photograph or video to be used by Inola Christian Church for ministry promotion, social media, website, and printed materials.

I don't give permission.

Guardian Authorization

By signing below, I verify that the information provided is accurate and up to date. I grant permission for my child to participate in the W.A.S.P. program at Inola Christian Church.

Number Input

Signature

Type your new text here.

Please Read:

Emergency Medical & Life-Saving Care Authorization

Physician & Insurance Information

Primary Care Physician

Physician Phone Number

Health Insurance Provider

Policy/Group Number

Consent for Emergency Treatment

In the event of a medical emergency, I understand that every effort will be made to contact the parents, legal guardians, or the emergency contact listed above.

If a parent, guardian, or emergency contact cannot be reached, I hereby give my consent and permission to the W.A.S.P. leaders, volunteers, and staff at Inola Christian Church to secure necessary medical treatment for my child. This includes, but is not limited to, administering first aid, performing CPR, calling an ambulance, arranging for transportation to a hospital or medical facility, and authorizing life-saving care or emergency procedures as recommended by medical professionals.

I release Inola Christian Church, its staff, and volunteers from all liability, and I understand that I am responsible for all medical expenses incurred in the event of an emergency involving my child.

Student Name Printed

Parent/Guardian Name (Printed)

Date

Parent/Guardian Signature: