Greystone Baptist Children 2023-2024 Medical Release and Permission Form

Greystone Baptist Children's Ministry 2023-2024 Medical Release and Permission Form
Student Information
Student's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Caretaker Contact Information
Parent/Caretaker 1 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parent/Caretaker 2 Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Information
Emergency Contact (if parent/caretaker is unavailable)*

First NameLast Name
Emergency Contact Relationship to Student*
Insurance Information
Emergency Contact Phone Number*
Please enter a valid phone number.
Is your student covered by a health insurance policy?*

YesNo
Insurance Company
Policy Holder
Policy Number
Group Number
Medical Information
Primary Physician
Phone Number
Please enter a valid phone number.
List Current Medications (with dosage and administration instructions for each medication)
Permission to Give Over the Counter Medications

IbuprofenAcetaminophenBenadrylAntihistamine
List Allergies (medications, food, other) and Describe Reaction and Management
Dietary Restrictions
Physical Restrictions
General Information (Check all that apply)

AsthmaDiabetesHeart DisorderFaintingSeizuresHeadachesConcussionEar InfectionsSleep WalkingMotion SicknessADHDAnxietyOtherN/A
Please provide additional information about any of the boxes checked above and any other special health concerns:
Date of Last Tetanus Shot

MonthDayYear
Date
Parental Permission
My child: Student's Name Here* may participate in all events, field trips, and service projects associated with Greystone Baptist Church in Raleigh, North Carolina for the 2023-2024 school year. I further give permission for my child to be transported to and from events by hired and volunteer drivers authorized by Greystone Baptist Church. Parent Initials*
Medical Permission
Parent Initials* I give permission for any Greystone staff or designated chaperone to render approval for medical treatment for my child until such time that I or my emergency contact can do so. The medical information on this form is correct to the best of my knowledge.
Media Release
Parent Initials* I give permission to use my child's likeness on the Greystone Baptist Church website or other related social media for events/activities associated with the church.
Liability Release
Parent Initials* I agree to release, saved, and hold harmless Greystone Baptist Church, its trustees, officers, directors, employees, agents, and representatives from any injury, harm, damage, or death which may occur to my child as a result of their participation in youth activities.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Greystone Baptist Children's Ministry 2023-2024 Medical Release and Permission Form

Student Information

Parent/Caretaker Contact Information

Emergency Contact Information

Insurance Information

Medical Information

Parental Permission

Medical Permission

Media Release

Liability Release