STUDENTS Medical/Permission Release Form

Parkhills Baptist Church- Annual Medical Release/permission

17747 San Pedro Avenue, San Antonio, TX 78232
Name of Minor/Participant:*

First NameLast Name
Parent E-mail*
example@example.com
T- Shirt Size
Date of Birth*

MonthDayYear
Date
Age: *
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Guardian:*

First NameLast Name
Parent Phone #:*
Parent Phone #:
Medical/Emergency Contacts

In the event of an emergency, give the name and phone number of friends or relatives we can contact who will know how to reach parents or guardians.
Doctor's Name:

First NameLast Name
Insurance Company:
Policy #:
Emergency Contact #1:*

First NameLast Name
Relationship #1:*
Emergency Phone #1:*
Emergency Contact #2:*

First NameLast Name
Relationship #2:*
Emergency Phone #2:*
List any food/drug allergies & medical conditions. *
Type N/A if not applicable
Date of last Tetanus (If known):

MonthDayYear
Date
List of Medications taken regularly. *
Write the name of medication/amount/when it is taken (Type N/A off not applicable)
Any other instructions regarding minor*
(Type N/A if not Applicable)
My teenager is a (choose 1):*
Authorization To Consent To Treatment:
I/we, the parent/guardian, of the above-named minor/participant, to take part in various trips, outings, and camps of Parkhills Baptist Church- San Antonio, Texas. i also give my permission for my teenager to be transported in vehicles used in conjunction with these events. I further give my permission for the designated/approved church representative or sponsor to secure any needed medical treatment for the above named son/daughter. I release the church representatives/sponsors from liability for accident or injuries on these trips or activities.

I further understand and agree that, in the event that the above named son/daughter be involved in any non-Christian or dangerous activities, I will pay his/her expense to be sent home immediately at the discresion of approved sponsors/and or church representatives.

I have supplied ,understood, and agree to all the information contained on this Medical Release/permission form.
Please Select:*

I, (The Parent/Legal Guardian) Give ConsentI, (The Parent/Legal Guardian) Do Not Give Consent
Parent/Guardian Signature:*
Date of Signature:*

MonthDayYear
Should be Empty:

Parkhills Baptist Church- Annual Medical Release/permission

Medical/Emergency Contacts

Authorization To Consent To Treatment: