SBC Medical Release Form

2024 Medical Release Form Second Baptist Church of Marion 308 S. Russell St. Marion, IL 62959 For all activities sponsored by SBC Marion during the 2024 calendar year (you only need to fill one out per year)
General Information
Name of participant
Address
City
State
Zip Code
Birthdate mmddyear

MonthDayYear
Date
Student Phone Number
Gender
Grade in School in January 2024
T Shirt Size
Mothers Name
Mother's Contact Info: Cell phone number
Email address
example@example.com
Father’s Name
Father’s Cell phone number
Alternate Contact Name
Alternate Contact Info: Cell phone number
Health Insurance Information
Primary Health Insurance Company
Name of Policy Holder
Policy
Group
Doctors Name
Phone #
Hospital Preference
Approx Date of last Tetanus Shot mmyear

MonthDayYear
Date
Secondary Health Insurance Company
Name of Policy Holder
Policy
Group
Other Health Info
Please list special medical issues diabetes medication allergies rare blood type high blood pressure etc
Please list any physical limitations that might hinder participation in activities allergies asthma etc
Please list any medications and doses that are taken regularly
1. For Minor Child I hereby certify that I am the parent or legal guardian of the named participant and I give my permission for him/her to take part in any of the activities sponsored by the Second Baptist Church of Marion, Illinois. I am aware that there might be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless Second Baptist Church of Marion, Illinois, its officers and directors, employees, and any parties volunteering on behalf of Second Baptist Church of Marion, from all actions, costs, expenses, or damages of any kind growing out of or related to any activities or transportation to and from the activities. In case of medical emergency, I hereby authorize the treatment of the named participant by a qualified and licensed medical physician if in the opinion of the physician the situation may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authorization is granted only after an attempt has been made to contact me (the parent/legal guardian
Signature of the Parent or Guardian

Clear
Date

MonthDayYear
Date
2. Adult Student (over 18) or Leader I hereby certify that to the best of my knowledge, I am in a state of health sufficient for me to take part in any of the activities sponsored by Second Baptist Church of Marion, Illinois, without jeopardizing my well being. I am aware that there might be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless Second Baptist Church of Marion, Illinois, its officers and directors, employees, and any parties volunteering on behalf of Second Baptist Church of Marion from all actions, costs, expenses or damages of any kind growing out of or related to any activities or transportation to and from the activities.
Signature of the adult student or leader

Clear
Date

MonthDayYear
Date
Should be Empty:

General Information

Health Insurance Information

Other Health Info