Beachpoint Church – Medical Release Form

Please fill out the following information for our records at Beachpoint Church.

Student's Name*

First
Last
Date of Birth*
Address*

Street Address
City
State / Province / Region
Zip / Postal Code
School
Parent Email Address
Home Phone*
Father's Name*

First
Last
Home Phone*
Work Phone
Cell Phone
Mother's Name*

First
Last
Home Phone*
Work Phone
Cell Phone
Other Contact

First
Last
Home Phone
Allergies to Drugs and/or Foods:
Last Tetanus Booster
Financial Responsibility of Child*
Insurance Company & Policy Number*
I (we) the undersigned parent, parents, or legal guardian, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis and treatment and hospital care which is deemed advisable by and is rendered under the general or special supervision of any staff physician and surgeon or emergency room physician and licensed under the provisions of the Medicine Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being rendered but is given to provide authority and power to render care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that efforts shall be made to contact the undersigned prior to rendering emergency treatment to the patient. This authorization is given to the provisions of Section 25.8 of the Civil Code of California.
This Release Is Valid For: (Please Select One)*
- 3 Months
- 6 Months
- 1 Year
* From today’s date.
Digital Signature*

By typing your first and last name in this field, you are agreeing that all information is accurate and are releasing Beachpoint Church from all liability.
Please Enter Today's Date*

General Information

Info@Beachpoint.com
17415 Magnolia St.
Fountain Valley CA 92708
tel. 714.847.3573
fax. 714.847.5669

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