Medical Liability Release Form 24-25

Please fill out this form prior to any off campus events for the 24-25 school year.
Parent Information

 
 
 
 
Student Information

 
 
 
Medical Information

All prescription medications must be sent in an original container from the pharmacy with the patient's name and current directions for taking ther medications on the typewritten label. The non-prescriptibe medications that will be available at events on an as needed basis are Tylenol, Ibuprofen, Advil, Benadryl, Antibiotic ointments, and Tums. If you would like your student to have any other non-prescriptive medication at an event please send it in the original container with your student's name on the container. It will be given according to the directions on the label.
Please select one option.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Authorization to Treat a Minor

By signing (electronically) I as the parent or legal guardian of the listed student authorize the leadership of Fort Scott Church of the Nazarene or FSN to care for the administration of general first aid treatment for any minor injuries recieved to my child during the event. If the injury sustained is life threatening, or requires emergency treatment, I authorize the leadership of FSN or its representative to summon any and all professional emergency personnel to attend, transport and treat my child.



I agree to release and hold harmless any staff and lay volunteers of Fort Scott Church of the Nazarene from any and all claim, suits, costs and actions, of any kind whatsoever, arising from their exercising the power granted by this authorization.

 

Description

Please fill out this form prior to any off campus events for the 24-25 school year.