Medical Release Form - Release and Indemnity

Annual Medical Release Form 2025

Release and Indemnity
Participant Information
Name

First NameLast Name
Grade
Age
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Red Bank Baptist/The Point Church member?
If no, I am a guest of
Emergency Contact Name
Relation to Participant
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Profile
Generally, the participant's health is
If Fair or Poor, please explain the condition.
List any medical difficulties for which you are being currently treated or that currently cause you problems. Explain.
List any medications or substances to which you are allergic.
List any previous surgeries or serious illnesses.
List any medications you are currently taking.
List any special diet or special needs.
Date of Tetanus Immunization

MonthDayYear
Date
Do you have health insurance coverage? Please send a photocopy of your insurance card with your child when participating in an overnight and/or out of town trip.
Permission for Medical Treatment, Photograph/Video Notice, and Release and Indemnity
My permission is granted for the staff, event director, church official, or adult present or in charge of First Aid, to obtain necessary medical attention in case of sickness or injury to my child. Also, I understand that as a participant, my child may be photographed or videotaped during normal event activities and these photos/videos may be used in promotional materials. I, the undersigned, do hereby verify that the above information is correct and I hereby release and forever discharge Red Bank Baptist Church, its directors, officers, employees, agents and all volunteer personnel from any and all claim, demands, actions or causes of action, past, present, or future arising out of any damage or injury while employed by or participating in events. I agree to indemnify the aforementioned for any and all claims, demands, damages, injuries, costs, suits or causes of action, past, present, or future, arising out of or caused by my child while participating in this event or while on property leased or owned by Red Bank Baptist. Complete and sign below (students under 18 years of age requires Parent/Legal Guardian signature).
Type Name of Signee Here
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Signature of Participant if age 18 or over, or Parent/Guardian if a Minor
Should be Empty:

Annual Medical Release Form 2025

Participant Information

Medical Profile

Permission for Medical Treatment, Photograph/Video Notice, and Release and Indemnity