Medical & Transportation Release Form
East Paris Baptist Church - 903-784-3258 - 725 N Collegiate Drive, Paris, TX 75460
Student Information
Additional students from the same household can be added at the bottom of the form.
Name
*
First Name
Last Name
Student's Phone Number
*
Please enter a valid phone number.
Student's Email Address
*
example@example.com
Birthdate
*
-
Month
-
Day
Year
Date
Recent picture of student
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Parent/Guardian & Emergency Contact
Parent/Guardian/Emergency Contact #1
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Parent/Guardian/Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Does your student have any known allergies? (If multiple students please specify which allergy goes to which student)
*
Yes
No
If yes, please list in detail the allergies.
Is your student currently on any medication? (If multiple students please specify which medication goes to which student)
*
Yes
No
If yes, please list all medications?
Name of your student's doctor
*
First Name
Last Name
Phone Number of your student's doctor
*
Please enter a valid phone number.
Authorization
By signing this form, I hereby give my consent for the above-named child/children/student to attend and take part in any and all activities for the 2025 calendar year. In the event of an emergency and I cannot be reached, I hereby give consent to church leadership/sponsors to sign for my student/children/student should it be necessary to receive medical treatment and to the church leadership/sponsors to administer medical care to my child/children.student which does not require a hospital visit. I understand that every effort will be made to provide the safest environment possible, but that accidents can and do occur. And I agree not to hold liable either the sponsoring church or the church leadership/sponsors in the case of an unforeseen event. I also agree to allow my child/children/student to ride in the church's transportation.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Additional Students
Additional students from the same household may be added on the next page.
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Additional Students from Same Household
Student #2
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Student #3
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Student #4
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Student #5
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
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