2024/25 VBC Medical Release Form

2024/2025 Student Medical Release Form
2181 CR 2246, Greenville, TX 75402

The following information will be used with registration forms completed for any student ministry event. Please take a few moments and complete all information correctly, i.e., check spelling of names, addresses, zip codes, phone numbers, etc.

Participant's Name*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

Gender*

Address*

Street Address Line 1

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant's E-mail

example@example.com

Participant's Mobile Number

Would you like to receive Text Messages about student ministry events.

Yes, I would like text messages.No, not at this time.

School*

Grade*

Highest grade completed at start of summer

Please list any food allergies or dietary restrictions

Parent / Guardian's Name*

First NameLast Name

Parent / Guardian's Number*

Please enter a valid phone number.

Relationship to Student*

In case of an Emergency and a parent or guardian can't be reached, please contact:

Emergency Contact*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Relation*

Name of Family Doctor

Office Phone Number

Name of Family Dentist

Office Phone Number

Health Insurance*

Policy Number

Primary Insured

Name of Insurance Company

Insurance Company Phone Number(s)

Please attach a copy of the front and back of your insurance card

Daily Medication Requirements: (optional)

Please list any medicines your student takes, and instructions for taking.

Other Important Medical Information: (optional)

Please include known allergies, conditions, etc.

I (We) hereby consent to the use of blood and/or blood products under the care of a licensed physician in the event of an emergency:*

DoDo Not

Please read in entirety and digitally sign form. Thank you!

Vansickle Baptist Church (together with their respective officers, employees and agents) and each volunteer assisting them are collectively designated by the abbreviation “VBC” throughout this entire form and the term “VBC” shall refer to them individually as well as collectively.
I (we) hereby give permission for my (our) child to attend and participate in activities sponsored by VBC.

I (we) acknowledge and understand the inherent risk associated with participation in VBC Student Ministry activities, including but in no way limited to: (1) slips, trips, and falls, (2) athletic injuries, and (3) illness, including exposure to and infection with viruses or bacteria. I (we) further acknowledge that the preceding list is not inclusive of all possible risks associated with VBC Student Ministry activities participation and that said list in no way limits the operation of this Agreement.
I (we) hereby authorize VBC to transport my (our) child to or from church and/or any other church related and sponsored activities and events.
I (we) authorize VBC to include my (our) child in routinely supervised water activities.
Further authorization and permission is hereby given to VBC to furnish any necessary transportation, food, and lodging for my (our) child.
I (we) (and on the 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.
I (we) hereby authorize VBC to take my (our) child to the before named physician or to the closest hospital for medical treatment in the event of an emergency in which neither parent can be reached after reasonable attempt to do so.
I (we) hereby authorize VBC 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) hereby do authorize VBC to dispense to my (our) child over-the-counter medications (according to proper dosage instructions) when reasonable deemed necessary.
I (we) do hereby authorize any physician, dentist, hospital or medical treatment center to treat my (our) child in the case of emergency in which the before named physician or dentist cannot respond.
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 release, forever discharge and agree to defend and hold harmless VBC 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 VBC.
The undersigned further hereby aggress to hold harmless and indemnify VBC from and against any claim against or loss incurred by VBC as the result of the negligent, willful or intentional acts of my (our) child, including any expense incurred attendant thereto.

Digital Signature of Parent*

Full name

Parent's Signature*

I understand that pictures / videos will be taken by the church for use on their website and social media, and that my child's participation in any student ministry event requires my consent for such use.*

Yes

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 VBC at its office at 2181 CR 2246, Greenville, TX 75402. I (we) acknowledge and agree that it is my (our) responsibility to notify Vansickle Baptist Church of any changes in medical condition, guardianship, address or telephone, in writing to the address listed at the beginning of this form.

VBC Medical Release Form

Parent / Guardian Information

Emergency Medical Information

Medical Release Waiver