Maryland Community Church :: Unite, Grow, Go


	SERVING "OUTSIDE THE CIRCLE DRIVE"

Parental and Medical Consent and Liability Release Form-

Please fill out the information below or download a pdf copy of the form by clicking here.

*Parent Name

*Email Address

*Name of participant:

*Age: *Grade: *Birth date

Address:

City

State

Zip

Home Phone

*Parents Phone: Business

Mother

Father

The undersigned does hereby give permission for our (my) child,
to attend and participate in
sponsored by MCC on .

Medical Consent:
< --Paste Medical Copy here.

Transportation Consent:
<--Paste Transportation Copy here.

Release From Liability:
<--Paste Liabilty Copy here.

*Signature of Parent: Date:

*Signature of Participant: Date:

Hospital Insurance: Yes No

*Name of Company:

*Phyician name Phone Number:

Any allergies or medical problems, allegies to medications (please list)

Please list any other info that you feel may be necessary:

Name of person other than parent to contact in case of an emergency.
Name: Phone Number: