Student Ministry Medical Release Form 2025

Student Ministry Medical Release Form 2025

218 S. 6th Street, Ponca City, OK 74601

I hereby give my permission for the below names student to take part in various church-sponsored youth trips, outings, events, and camps. It is understood that the below named student is not able to participate without the a signature from a parent/guardian of that student. I further give my permission for the church representatives or sponsors of the trips or activities to secure needed medical treatment in the event that I cannot be reached for such permission. I release the church representatives and/or sponsors from liability for accident, injuries, or illnesses on these trips or activities, even those which are the result of negligence.

I further understand and agree that in the event that the below-named son/daughter is involved in activities that violate or compromise the rules, policies, or purposes of First Baptist Church of Ponca City, I will pay and accept full responsibility for the return and release of my child back to my custody and care. that

Student's Name (Required)

First NameLast Name

Student's Birthdate (Required)

Date

Student Age (Required)

Student Grade Fall of 2025 (Required)

Student Gender (Required)

Student's Address (Required)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name (Required)

First NameLast Name

Parent/Guardian Phone Number (Required)

Please enter a valid phone number.

Secondary Parent/Guardian Name (Required)

First NameLast Name

Secondary Parent/Guardian Phone Number (Required)

Please enter a valid phone number.

List Known Food/Drug Allergies: (Required)

Medication(s) Taken Regularly: (Required)

Date of Last Tetanus Shot:

Family Medical Insurance Company: (Required)

Policy Number or Group Number: (Required)

I have read and understand this Medical Release Form/Waiver. In exchange for patricipation in the youth trips, outings, events, and camps, it is agreed that First Baptist Church of Ponca City and its representatives or sponsors are not liable for damages and/or harm resulting from or occuring during participation. My signature represents that all of the information contained herein is true and correct. I, hereby, accept and assume all the risks of injury associated with the activities of First Baptist Church of Ponca City.

Unless terminated in writing, this release shall be effective for the year of 2025.

Type Full Name (Required)

Sign Name Below (Required)

Signature