SBC Medical Release Form

2025 Medical Release Form Second Baptist Church of Marion 308 S. Russell St. Marion, IL 62959 For all activities sponsored by SBC Marion during the 2025 calendar year (you only need to fill one out per year)

General Information (please print clearly)

Name of participant

Address

City

State

Zip Code

Birthdate mmddyear

Date

Phone Number

Gender

Grade in school in January 2025:

T Shirt Size

Mothers Name

Mother's Contact Info: Cell phone number

Email address

example@example.com

Name

Cell phone number

Alternate Contact Name

Alternate Contact Info: Cell phone number

Home/Work/Other phone number

Primary Health Insurance Company

Name of Policy Holder

Policy

Group

Doctors Name

Phone #

Hospital Preference

Approx Date of last Tetanus Shot mmyear

Date

Secondary Health Insurance Company

Name of Policy Holder

Policy

Group

Medical Information- Continued

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

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

Date