YEARLY MEDICAL AUTHORIZATION

YEARLY MEDICAL AUTHORIZATION

This form is for any participant regardless of age that will be participating in an event (camp, retreats, VBS, mission trips, etc.) that is organized and or directed by Lakeside Baptist Church
What ministry department will you be serving?
Participants Name*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Participants Phone
Parent/Guardian Name(s)
Doctor's Name
Doctor's Phone
Please enter a valid phone number.
Health Ins. Contract #
Member ID
Insurer*
Please List Any Allergies
List any medication or drugs taken regularly
Please upload a copy your insurance card.

Front of insurance card
Cancelof
Back of insurance card
Cancelof
Assumption of Risk

I acknowledge that there are certain risks associated with participation in any activity or program, including transportation accidents, injuries, loss of personal items, criminal actions beyond the control of Lakeside Baptist Church, or other harm that may occur to my child. I assume the risk associated with such activities and release Lakeside Baptist Church of any liability for such.
In Case of a Medical Emergency for Minor under 18 years of age.

It is my understanding that a church representative will attempt to notify me in case of a medical emergency involving participant. If parent/guardian cannot be reached, then I authorize the church representative to hire a doctor or other health-care professional, and I give my permission to the doctor or other health-care professional to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred. I will notify the church if I feel there are any health considerations that would prevent my student's participation in an activity. I also give my permission for church leaders to restrict my student from participation in any activity, which they have any question about for health or other reasons.
Emergency Contact if parent/guardian cannot be reached:

First NameLast Name
Phone Number
Please enter a valid phone number.
Photo/Video Consent

I grant and convey to Lakeside Baptist Church all right, title, and interest in any and all photographic images, video, or audio recordings made of the "PARTICIPANT" during Lakeside Baptist Church events, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
Please Check One:

I give permission for photographs and videos of the "PARTICIPANT", taken while in church functions and events, and for special emphases to be placed: in Lakeside Baptist Church publications printed and digital; on Lakeside Facebook Page and other social media.I do NOT give permission for photographs and videos of the "PARTICIPANT", taken while in church functions and events, and for special emphases to be placed: in Lakeside Baptist Church publications printed and digital; on Lakeside Facebook Page and other social media.
Digital Signature Agreement:*

I consent to signing this document digitally and agree that a printed or digital copy of this signed agreement shall be equally valid and binding.
Parent/Guardian Name (Printed)*
Parent/Guardian Signature*

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Date*

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Date
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