Medical Release Form

Submit a Medical Release form for each child under 18 Optional for adults. (Please make a copy for each individual.) I give permission for my child named below to participate in the Illinois Yearly Meeting Children’s Sessions or High School Program and to participate in all planned program activities, both on and off campus. I hereby release Illinois Yearly Meeting, its staff, and volunteers from liability for any injury or illness that my child may experience during Yearly Meeting Annual Sessions. In the event of an emergency, I hereby authorize Yearly Meeting organizers, or the below-named sponsor, to consent to any medical or surgical care advised by licensed health care providers. I hereby release Illinois Yearly Meeting from any liability, legal or financial, for emergency care provided to my child. I expect to be informed of emergency care as soon as possible.

(Child's) Name _____________________________________   Birthdate_____________

Activity restrictions_______________________________________________________

Known allergies__________________________________________________________

Date of last tetanus immunization __________________

In event of emergency, please call:

Name ___________________________________________  Phone _________________

Name of insurance company _______________________  

Policy number ______________

Parent's signature ___________________________________  Date  _________________

(Please attach a copy of your insurance card)

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SPONSOR INFORMATION
(Required for those under 18 attending without their parents.)
It is understood that the sponsor acts “in loco parentis.”

Sponsor’s name ____________________________            

Meeting _________________________________

Parent’s signature ___________________________________