Medical Release Statement

Participant Name *

Address *

Cell Phone *

Parent/ Guardian Name and phone *

Emergency Contact Name *

Emergency Contact Phone Number *

Date of Birth *

Family Physician and Phone Number *

Please list any allergies/reactions your child may have. (allergies food, flowers, pollens, grasses, or medications. *

Are there any limitations your child may have pertained to recreational activities or exercise? *

May your child be given pain medication as needed, such as aspirin, Tylenol or Ibuprofen? *

I give my permission for the above mentioned child to attend an event at Cowboy Church Ministries Inc DBA Silverado Cowboy Church. In the event of an emergency where medical treatment is required, I give my permission to the staff and sponsors to obtain the services of a licensed physician and notify me as soon as possible. I also release Cowboy Church Ministries INC dba Silverado Cowboy Church, their staff, and sponsors of any and all liability. My name printed below acts as my signature. *

Name