Permission Form and Medical Release 2023

Permission Form

Washington Avenue Baptist Church Student Ministry
By signing this form and completing the Medical Release form, you are giving permission for your child to participate in this activity.

As the parent or legal guardian of acknowledge and understand my child's participation in trips, events, and activities offered by Washington Avenue Baptist Church. Trips, events, and activities of this nature inherently carry with them a degree of risk and danger to my child. I consent to my child's participation in this activity. I acknowledge and understand that this parental authorization, consent and release have the same force and effect regardless of whether the activities engaged in are free or if a fee is charged. Further, I personally assume, on my child's behalf, all risk in connection with said activity for any harm, injury or damages that may befall my child as a result of my child's participation in the activity, whether foreseen or unforeseen, and I still wish to allow my child to proceed with the activity.

In consideration of my child being allowed to participate in this activity, on behalf of my child, I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Washington Avenue Baptist Church and any staff, leadership and/or volunteers from any and all claims, demands, or causes of action, which are in any way connected with my child's participation in this activity.

I understand that it is my obligation to inform and update Washington Avenue Baptist Church of any and all health considerations or medical conditions that would restrict my child's participation in this activity.

Iacknowledge by signing this document, that if anyone is hurt or property is damaged during my child's participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against the church on the basis of any claim from which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions remain in full force and effect. I have fully informed myself to the contents of this parental authorization, consent and release by reading it before I signed it.
Parent/Guardian Name
Date

MonthDayYear
Date
Signature

Clear
MEDICAL RELEASE

Washington Avenue Baptist Church
Participant Name
Birthdate

MonthDayYear
Date
Sex
Address
Parent/Guardian
Emergency Phone
ADDITIONAL CONTACT IN CASE OF EMERGENCY:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Health History

Please answer Yes or No where applicable
Last Tetanus Shot

MonthDayYear
Date
heart trouble
operation
serious health problem/other
Please explain
ALLERGIES:

Please answer Yes or No where applicable
insect stings
penicillin
foods
poison ivy
If you have allergies to other drugs or foods, please list them:
MEDICATIONS: List medications you are currently taking, including vitamins. List time and amount you are currently using.
OVER-THE-COUNTER MEDICATION PERMISSION: Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a student ministry event?
No. Contact me or get medical help if my child has any minor medical concerns.Yes. I give permission for an adult youth leader to give my child approved over-the
Parent signature

Clear
PHYSICIAN: State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems:
DENTIST: State the name, address, and phone number of your dentist (and orthodontist if applicable)
Please provide information concerning any insurance benefits for which you are eligible:
Insurance Carrier
Policy #
Insured's Name
Group Phone # of Insurance Carrier
I understand that Washington Avenue Baptist Church (ministry) carries insurance coverage

which, consistent with the exclusions, limitations and terms thereof, may provide benefits over and above any personal medical and hospitalization coverages available to my family. understand that any personal medical and hospitalization insurance available to my family will provide primary coverage and ministry's medical and hospitalization coverage (subject to the exclusions, limitations and provisions in the ministry's policy) may provide secondary or excess coverage. I agree to apply first for benefits from the personal hospitalization and medical coverages available to my family, if any, before applying for benefits that may be available from the ministry's medical and hospitalization coverage.

I further understand that, in the event that my child requires medical or dental treatment while engaged in any Avenue Students activity, reasonable efforts will be made to contact my family; however, if they cannot be reached, I hereby consent and give permission to the ministry's sponsor or any adult counselor acting on behalf of the ministry with respect to the activity, as agent for me, to consent to any X-ray examination; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my medical allergies, medications being taken, medical problems and other pertinent information.
(Participant Name)
(Parent or Guardian)
Signature

Clear
Should be Empty:

Permission Form

MEDICAL RELEASE

ADDITIONAL CONTACT IN CASE OF EMERGENCY:

Health History

ALLERGIES: