0e4895057_1455824014_childrens-medical-release-2

Parkhills Baptist Church

Medical Release Form
Childs Name

First NameLast Name
Childs Date of Birth*

MonthDayYear
Date
Gender*
Age/Current Grade*
Parent or Guardian Info
Parents/Guardians name:*

First NameLast Name
Parents Phone #*
Please enter a valid phone number.
Email*
example@example.com
Address*

Address

Street Address Line 2

CityState / Province

Zip
Emergency Contacts
Contact #1 Name*
Contact #1 Relationship*
Contact #1 Phone*
Contact #2 Name*
Contact #2 Relationship*
Contact #2 Phone*
Medical Information
Insurance Company
Policy
Name of Primary Holder
Insurance Company Phone Number
Date of Last Tetanus Shot

MonthDayYear
Date
Family Physician
Family Physician Phone #
List any allergies or medical problems
List any medicines your child takes (prescription or over-the-counter). List the name of medicine frequency and dosage.
List any medicines your child takes (prescription or over-the-counter): Frequency

I, the undersigned, do hereby grant permission for my child/charge to be transported with the church staff and/or chaperones and to attend any event for which I have registered. I also give my permission for a church staff member or chaperone or camp worker to seek medical attention for my child in case of an emergency. I will not hold Parkhills Baptist Church financially responsible for the emergency medical care of my child. (Parkhills Baptist Church does not assume financial responsibility but does wish to provide emergency medical care By signing this form, you are giving the appropriate church staff member and /or chaperone permission to call EMS to transport, or to obtain medical attention for your child.
Parents Signature

Clear
Date

MonthDayYear
Date
This form is valid for all events from date of signature to end of current calendar year. If any information changes, please complete a new form.
Should be Empty:

Parkhills Baptist Church

Parent or Guardian Info

Emergency Contacts

Medical Information