VBS Medical Release Form

Get in touch

555-555-5555

mymail@mailservice.com

This Medical Authorization Form (MAF) is required for Vacation Bible School. Once completed, this form will cover all Prince of Peace activities on church property and any church events off property.

Only parents/guardians for a minor are eligible to complete this form. Forms will not be accepted if completed by a minor. The information used to complete this form is sent directly to a church email address. Once the summer is completed, this medical authorization form will be void; also, any existing information will be deleted/shredded by staff personnel.

VBS Medical & Consent Form

Parent/Guardian 1 Full Name:

Parent/Guardian 1 Email:

Parent/Guardian 1 Phone:

Parent/Guardian 2 Full Name:

Parent/Guardian 2 Email:

Parent/Guardian 2 Phone:

Primary Address

City:

State:

Zip Code:

Youth 1 Full Name

Provide medical conditions, diet restrictions, allergies, or special considerations?

Any additional information you would like us to know about the well being of your child?

Youth 2 Full Name:

Provide medical conditions, diet restrictions, allergies, or special considerations?

Any additional information you would like us to know about the well being of your child?

Youth 3 Full Name:

Provide medical conditions, diet restrictions, allergies, or special considerations?

Any additional information you would like us to know about the well being of your child?

Youth 4 Full Name:

Provide medical conditions, diet restrictions, allergies, or special considerations?

Any additional information you would like us to know about the well being of your child?

Treatment Consent

By selecting this checkbox, I/we, the parent/guardians of said child(ren) give permission for my/our children to participate in youth programs from June 2024 to August 2024 organized by Prince of Peace Lutheran Church of Schaumburg, Illinois. I/we understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form and/or the registration form. In the event I/we cannot be reached in an emergency, I/we hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or an injection, anesthesia, or surgery to my/our child(ren) as deemed necessary.

Insurance Consent

I/we understand that my/our insurance coverage for my child(ren) will be used as primary coverage in the event medical intervention is needed. Coverage by Prince of Peace Lutheran Church through its insurance policy is only a potential backup for what my/our family's insurance does not cover.

Liability Consent

I/we understand all reasonable safety precautions will be taken at all times by Prince of Peace Lutheran Church and its agents during the events and activities. I/we understand the possibility of risk. I/we agree not to hold Prince of Peace Lutheran Church, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred by the child(ren) on this form

Image Consent

I/we consent to the use of video images, photographs, audio recording, or any other visual or audio reproduction that may be taken of the child(ren) of this release during these programs to be used, distributed, or shown as Prince of Peace Lutheran Church sees fit.

True & Complete

By checking this box, I/we attest as the parent and/or legal guardian of the above named child(ren), that the information provided on this form is true and complete.

Parent/Guardian Signature

Parent/Guardian Signature Date

VBS Medical & Consent Form

CONTACT US

930 W. Higgins Rd, Schaumburg, IL 60195

P: 847-885-7010

E: church@princeofpeace.net

Terms of Service

Privacy Policy