Annual Medical Release Form

Annual Medical Release Form

Warren Students
Please complete the entire form and upload a picture of the Front side and Back side copy of your insurance card at the end of this form
Full Name of Student*

First NameLast Name
Which campus do you attend?
Date of Birth*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*
Graduation Year*
School*
Parent's Home Phone*
Please enter a valid phone number.
Parent's Cell Phone*
Please enter a valid phone number.
Parent's Work Phone*
Please enter a valid phone number.
Parent's Email*
example@example.com
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Alternate Emergency Contact Phone Number
Please enter a valid phone number.
Family Physician Name*
Family Physician Phone Number*
Please enter a valid phone number.
Medications currently taking: (list all, even vitamins)*
Last Tetanus Shot*
please state unknown if date is not known
Blood Type*
please state unknown if not known
List details of all allergies (medical, environmental, or food):*
Has the student been prescribed an EpiPen? (if yes, we expect the student to always have the EpiPen available.)*
Has the Student been diagnosed with Asthma or Diabetes*
Can the student swim and tread water?*
Do they have a fear of water?*
Parent Permission to give (please select)*

AdvilTylenolAlevePepcidBenedrylNoneOther
If other is selected above, please specify what medicine.
Special Instructions regarding student:*
My student First Name* Last Name* may participate in all Warren Baptist Church events. As a parent or guardian, I authorize an adult Counselor or Youth Pastor to make legal decisions, medical decisions, or otherwise, concerning said minor during the time of the student ministry event. I also agree that I will immediately notify the Student Ministry Office of W.B.C., in writing, of any changes to the information above, medical or otherwise. I hereby release Warren Baptist Church and its sponsors of any legal responsibilities and liability in the event of an accident or injury.

As a parent or guardian I have carefully and truthfully provided all the information requested and give my permission for my child to participate in W.B.C. student events. I also give my consent for photos and videos of all youth events that may include my student to be published/printed for the purpose of event recaps and future event promotions.

My child & I have read & understand that he/she will be subject to all the rules, regulations & policies outlined in the Student Ministry Guidelines. Please sign below.
Parent/Guardian signature*

Clear
Student signature*

Clear
Please attach a copy of the FRONT side of your insurance card*

Cancelof
Please attach a copy of the BACK side of your insurance card*

Cancelof
Student Ministry Guidelines

LOVE GOD | LOVE OTHERS | PROVE IT

These guidelines are here to protect the students and to provide the best possbile atmosphere for you to enjoy our event and grow in Christ.

By coming to this, and all WSM events you have agreed to abide by each rule. If you willfully disobey the WSM guidelines, you forfeit any free time and/or the right to stay at the event. If there is a need to dismiss any student to go home, transportation home will be at the parent's expense and attendance at any future events will be pending.

IN GENERAL: Be where you are supposed to be, when you are supposed to be, doing what you're supposed to be doing...& "When in doubt, DON'T!"

I will respect my WSM Volunteers & Leadership, I will respect everyone else around me. Each student who attends a WBC event is expected to conduct him/herself in a Christ-like manner at all times (1 John 2:6)
Should be Empty:

Annual Medical Release Form

Please complete the entire form and upload a picture of the Front side and Back side copy of your insurance card at the end of this form