• COKER FAMILY MINISTRIES

    COKER FAMILY MINISTRIES

  • Adult Leader Medical Form Effective August 1, 2025- July 31, 2026

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of last Tetanus shot
     / /
  • Format: (000) 000-0000.
  • Consent To Treat And Release Of Liability

    A copy of the front and back of the medical insurance card must be provided with this form.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  

    I have completed the contact information, the medical history information, and provided a copy of the insurance card. Effective immediately, I assume all risk and hazards and do hereby release and agree to hold harmless Coker Methodist Church and its servants, volunteers, agents and employees from all liability for personal injury or property damage for all actions taken in good faith during church activities. Additionally, I hereby release and agree to hold harmless the church and its servants, volunteers, agents, and employees from all liability in the event that I contract the COVID-19 virus during a church activity. In the event I cannot be reached or cannot communicate in an emergency, I hereby give my permission to the physician, hospital, or medical service selected by the leaders of the church to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for myself as named above. It is understood that a conscientious effort will be made to communicate with me or the emergency contact listed before any action is taken. I accept responsibility for any and all expenses incurred from medical treatment provided. I have read this release and understand its term and execute it voluntarily and with full knowledge of its significance.

  • Date
     / /
  • Coker Methodist Church I Family Ministries I 231 E. North Loop Rd., San Antonio, TX 78216 1210.494. 3455

  •  
  • Should be Empty: