2017 Elevate Medical Form - Student

This medical emergency form must be completed and initialed by the parent or guardian and accompany the youth who wishes to participate in Elevate activities. The purpose of this form is to make it possible for parents or guardians to authorize the provision of medical treatment for minors who become ill or injured while under the supervision of Elevate activities.
  • Please list any special needs, allergies, conditions, disorders, current medications, or anything else mental or physical that would help us serve your student in the best possible way.
  • Please give us the name of a person we can call in the event an emergency occurs and we are unable to reach you.
    As the parent/ guardian, I give my permission for an Elevate Ministry Leader, at their discretion, to administer over the counter medication(s) as needed to my child
    I understand that, while my student participates in the Elevate activities, he or she is responsible to abide by the rules set forth by the leaders and supervisory personnel. Any serious inflation of these rules and/ or disregard of leadership by him/ her can result in dismissal from the program or event. If he/ she is dismissed from the program or event, I agree to assume the cost and responsibility of him/ her returning home, and of any damages which may have been caused by him/ her.
  • (Please initial here) I understand that my initials act as an electronic signature. I verify all information is correct to the best of my knowledge.