Student Medical Travel Release Form -

Kathleen Baptist Church

Student Medical & Travel Release Form June 1, 2024 to May 31, 2025
Form Date (start)

MonthDayYear
Date
Form Date (end)

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Student's Birthday*

MonthDayYear
Date
Grade
Gender*

MaleFemale
Father's Name

First NameLast Name
Father's Work Number
Please enter a valid phone number.
Father's Cell Phone
Please enter a valid phone number.
Mother's Name

First NameLast Name
Mother's Work Number
Please enter a valid phone number.
Mother's Cell Phone
Please enter a valid phone number.
Guardian

First NameLast Name
Guardian's Work Phone
Please enter a valid phone number.
Guardian's Cell Phone
Please enter a valid phone number.
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
Emergency Contact's Relationship to student
Required Emergency Medical Information
Family Physician

First NameLast Name
Office Phone
Please enter a valid phone number.
Family Dentist

First NameLast Name
Dentist Phone
Please enter a valid phone number.
Does this Student have medical insurance

YesNo
Name of Insurance Company
Policy Number
Insurance Company Phone Number
Please enter a valid phone number.
Name of Primary Insured

First NameLast Name
Date of Birth of Primary Insured

MonthDayYear
Date
Daily Medication Requirements:
Medicine 1
Prescribed Dosage for Medicine 1
Time of day to take Medicine 1
Medicine 2
Prescribed Dosage for Medicine 2
Time of day to take Medicine 2
Medicine 3
Prescribed Dosage for Medicine 3
Time of day to take Medicine 3
Food Allergies
Medicine Allergies
Other Important Medical Information
Other Important Medical Information (cont.)
Release

Please Read Carefully the following. If you agree please Sign below along with your student's signiture.
KATHLEEN BAPTITST CHURCH (Together With Their Respective Officers, Employees and Agents) and Each Volunteer Assisting Them Are Collectively Designated By The Abbreviation “KBC” Throughout This Entire Form and the Term “KBC” Shall Refer to Them Individually As Well As Collectively.

·I (we) hereby authorize KBC to take my (our) child for medical treatment in the event of an illness or injury in which neither parent can be reached after a reasonable attempt to do so.

·I (we) do hereby authorize any physician, dentist, hospital or medical treatment center to treat my (our) child in the case of emergency. The undersigned adult shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume and be responsible for the payment of all transportation costs.

·I (we) hereby authorize KBC to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care to be rendered to my (our) child under the general or special supervision and on the advice of any physician or dentist representing to be licensed on the medical staff of a hospital or medical care facility, whether such diagnosis or treatment is rendered at the office of said physician or at the said facility or hospital.

·I (we) herby do authorize KBC to dispense to my (our) child any over-the-counter medications (according to proper dosage instructions) when reasonably deemed necessary.

·I (we) hereby give permission for my (our) child to attend and participate in activities sponsored by KBC.

·I (we) hereby authorize KBC to transport my (our) child to or from church and/or any other church related and sponsored activities and events.

·I (we) authorize KBC to include my (our) child in routinely supervised water activities.

·I (we) hereby release, forever discharge and agree to defend and hold harmless KBC from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the undersigned adult and the child/participant that occur while said child is participating in any trip or activity with KBC.

·I (we) (and on behalf of my (our) child) hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein. Further authorization and permission is hereby given to KBC to furnish any necessary transportation, food, and lodging for my (our) child.

·The undersigned further hereby agrees to hold harmless and indemnify KBC from and against any claim against or loss incurred by KBC as the result of the negligent, willful, or intentional acts of my (our) child, including any expense incurred attendant thereto.

·The medical consent and liability waiver provisions hereof shall remain in full force and in effect until written notice of revocation or withdrawal is received by KBC at its office at 3939 Second Street NW ● Lakeland, FL 33810.

·I (we) acknowledge and agree that it is my (our) responsibility to notify Kathleen Baptist Church of any changes in medical condition, guardianship, address or telephone, in writing to the address listed at the beginning of this form.
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Legal Disclaimer about electronic Signature

Each of the parties hereto agrees that the transaction consisting of this Agreement (and, to the extent permitted under applicable law, each officer’s certificate, receipt or similar closing document delivered in connection with the closing of this transaction) may be conducted by electronic means. Each party agrees, and acknowledges that it is such party’s intent, that if such party signs this Agreement (or, if applicable, such closing document) using an electronic signature, it is signing, adopting, and accepting this Agreement or such closing document and that signing this Agreement or such closing document using an electronic signature is the legal equivalent of having placed its handwritten signature on this Agreement or such closing document on paper. The use of electronic signatures and electronic records (including, without limitation, any contract or other record created, generated, sent, communicated, received, or stored by electronic means) shall be of the same legal effect, validity and enforceability as a manually executed signature or use of a paper-based record-keeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act and any other applicable law, including, without limitation, any state law based on the Uniform Electronic Transactions Act or the Uniform Commercial Code.
Student Signature

Clear
Legal / Guardian Signature

Clear
Legal / Guardian Signature

Clear
Please take a picture of the FRONT of your student's insurance card.
Please take a picture of the BACK of your student's insurance card.
Should be Empty:

Kathleen Baptist Church

Required Emergency Medical Information

Daily Medication Requirements:

Release