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Irving Church Youth
Medical Release Waiver

Child Information

Age
Birthdate
Month
Day
Year
Grade Level

Emergency Contact

Relation to Child

Emergency Contact #2 (optional)

Relation to Child

Medical Information

Does your child have any of the following?
Please rate your child's swimming ability
Good Swimmer
Fair Swimmer
Non-Swimmer
May your child be given over the counter medication? Select all that apply
Does your child have allergies to:

I give permission for my child (named above) to participate in and travel to and from all activities sponsored/organized by Irving Church. I understand that it is my responsibility to inform the leaders of any updates to this form. Furthermore, in the event I cannot be reached in an emergency, I hereby give permission to the adult leaders supervising the activity to administer emergency treatment to my child for any accident or illness and to act in my stead in approving necessary medical care until I can be reached.

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Date
Month
Day
Year
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