Medical Waiver and Information

indicates a required answer

I understand the character of this program, and with such knowledge I voluntarily release Spectrum Christian Homeschool Community and the members of the Oversight Committee and their representatives, including all staff and teachers, as well as Hope Baptist Church and its representatives, including all staff, from any and all liability related to the activities of this program. In the event that medical attention is required, I understand that every effort will be made to contact me. However, in the event that I cannot be reached, I give my permission to the staff to secure the services of a licensed physician to provide the necessary treatment including anesthesia, surgery, medication, and intravenous (IV) medications.

1. *	Emergency Contact Name & Home Phone Number

2. *

Is this person a:

Parent		Relative
Neighbor		Other

3. *	Emergency Contact Name & Cell Phone Number

4. *

Is this person a:

Parent		Relative
Neighbor		Other

5. *	Children’s Physician’s Name and Phone Number

6. *	Insurance Company

7. *	Policy # and/or Group #

8. *	Address of Insurance Company

9.	My child has permission to use the following medications without calling home for permission
	Use your Ctrl & Shift keys to select multiples.

10.	Explanation of other medication