Central Baptist Church 2009 Medical Release Form
Name: __________________________________________ Age: _______ Phone: _____________
Address: ______________________________ City: ______________ State/Zip: ______________
In case of an emergency, notify: ___________________________ Phone #:___________________
Insurance Company: _____________________________ Policy #: _________________________
Name of insured on policy: _________________________________________________________
(Please provide a copy of insurance card)
Check below to give appropriate information
Asthma Sinusitis Stomach problems Kidney Trouble Diabetes Heart Trouble
Childhood Diseases:
Chicken Pox Measles Mumps Whooping Cough Scarlet Fever
Previous Operations or illness:______________________________________________________________
Current Medications: _____________________________________________________________________
Allergies: Foods: ________________________________________________________
Penicillin; other drugs: _____________________________________
Insects Stings/Bites: Yes No Poison sumac, oak, ivy: Yes No
Other: __________________________________________________
Special Diet: (Name) _____________________________Can you take Tylenol or Advil? Yes No
Parental Consent
I,_____________________ (Parent/guardian) give the adult leaders of Central Baptist Church, the authority to obtain necessary medical attention in the case of sickness or injury for ____________________________________ (Student's name).
I, _____________________ (Parent/guardian) give my permission for my (son/daughter), __________________________ to attend Central Baptist Church Student Ministries on and off-campus events. I, the undersigned, do hereby release, and forever discharge all sponsors and Central Baptist Church from any an all claims, demands, actions or cause of action, past, present, or future arising out of any damage or inquire while participating in the event. I further accept financial responsibility for the return of my child(ren), should the adult supervision find it necessary to send him/her/them home (as applicable).
Parent/guardian signature _________________________ Date ____________
On this ________ day of ______________ 2008 ______________ personally appeared before me, and in my present executed the within and foregoing permission and release form.
Notary Public ______________________
My commission expires________________
THIS FORM MUST BE NOTARIED WITH A SEAL FOR VALIDATION
Name: __________________________________________ Age: _______ Phone: _____________
Address: ______________________________ City: ______________ State/Zip: ______________
In case of an emergency, notify: ___________________________ Phone #:___________________
Insurance Company: _____________________________ Policy #: _________________________
Name of insured on policy: _________________________________________________________
(Please provide a copy of insurance card)
Check below to give appropriate information
Asthma Sinusitis Stomach problems Kidney Trouble Diabetes Heart Trouble
Childhood Diseases:
Chicken Pox Measles Mumps Whooping Cough Scarlet Fever
Previous Operations or illness:______________________________________________________________
Current Medications: _____________________________________________________________________
Allergies: Foods: ________________________________________________________
Penicillin; other drugs: _____________________________________
Insects Stings/Bites: Yes No Poison sumac, oak, ivy: Yes No
Other: __________________________________________________
Special Diet: (Name) _____________________________Can you take Tylenol or Advil? Yes No
Parental Consent
I,_____________________ (Parent/guardian) give the adult leaders of Central Baptist Church, the authority to obtain necessary medical attention in the case of sickness or injury for ____________________________________ (Student's name).
I, _____________________ (Parent/guardian) give my permission for my (son/daughter), __________________________ to attend Central Baptist Church Student Ministries on and off-campus events. I, the undersigned, do hereby release, and forever discharge all sponsors and Central Baptist Church from any an all claims, demands, actions or cause of action, past, present, or future arising out of any damage or inquire while participating in the event. I further accept financial responsibility for the return of my child(ren), should the adult supervision find it necessary to send him/her/them home (as applicable).
Parent/guardian signature _________________________ Date ____________
On this ________ day of ______________ 2008 ______________ personally appeared before me, and in my present executed the within and foregoing permission and release form.
Notary Public ______________________
My commission expires________________
THIS FORM MUST BE NOTARIED WITH A SEAL FOR VALIDATION
