Name_________________________________________________________ Age_______ Birthdate____________
Address_____________________________________________ City____________________ State_______ Zip_________________
Home Phone__________________________________________
Medical Insurance Company_________________________________ Policy #____________________________________
Mother's Name____________________________________________ Contact Phone #___________________________________
Father's Name_____________________________________________ Contact Phone #___________________________________
Other Emergency Contact: ________________________________ Contact Phone #____________________________________
Physician__________________________________________________ Office Phone #_____________________________________
If necessary, describe in detail the nature and severity of any physical or psychological ailment, ilness, or condition of which adult leaders should be aware, including allergies, conditions for which you are currently taking medication, or conditions that might restrict your activity:
This consent form gives permission to seek whatever medical attention is deemed necessary and releases the Webster Groves Christian Church and Union Avenue Christian Church and its staff against any personal losses of the above named individual.
Your signature___________________________________________________ Date__________________
Parent/Guardian signature (if under 18)__________________________________________ Date__________________