Permission & Medical Release Form

Permission & Medical Release Form

Washington Avenue Baptist Church Student Ministry
PERMISSION FORM
As parent/legal guardian of First Name Last Name, I am aware that my child will be involved in off-campus activities at Washington Avenue Baptist Church and give my permission for the subject of this release to attend these activities. Furthermore, I authorize Washington Avenue Baptist Church to transport my child to and from the activities.

I understand all reasonable safety precautions will be taken at all times by Washington Avenue Baptist Church and its agents during the activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Washington Avenue Baptist Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

I hereby authorize Washington Avenue Baptist Church to take my child to Urgent Care or the Emergency Department at Cookeville Regional Medical Center for medical treatment in the event of an emergency in which neither parent can be reached.
Parent/Guardian Name

First NameLast Name
Signature

Clear
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
MEDICAL RELEASE

Washington Avenue Baptist Church Student Ministry
Participant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Address
Emergency Contacts

In addition to parent/guardian already listed above.
Emergency Contact #1

First NameLast Name
Emergency Contact #2

First NameLast Name
Health History
Last Tetanus Shot

MonthDayYear
Date
Please check if your child has/has had any of the following:

Heart issuesSurgeriesSerious health issues
If you checked any of the above, please give details.
Allergies
Is your child allergic to any of the following?

Insect bites/stingsMedicationsFoodsPoison Ivy/Oak
Please list any medications or food allergies your child has.
MEDICATIONS: Please list medications your child takes, including vitamins. List dosage and times to administer the medication. Please send all medications IN THE PRESCRIPTION BOTTLE. (No medications without a prescription label will not be administered.)
OVER-THE-COUNTER MEDICATION PERMISSION: Do you give permission for your child to be given OTC medication as needed and as directed on the label to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomach ache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a student ministry event?

YesNo
Signature

Clear
PHYSICIAN: State the name, address, medical specialty, and phone number of your family physician and of any other physician who should be consulted with in the event of an emergency or medical problem.
DENTIST: State the name, address, and phone number of your dentist (and orthodontist if applicable).
INSURANCE: Please provide information regarding any insurance benefits for which your child is eligible.
Insurance Carrier
Phone # of Insurance Carrier
Insured's Name
Policy #
Group #
I understand that Washington Avenue Baptist Church (Student Ministry) carries insurance coverage which, consistent with the exclusions, limitations, and terms thereof, may provide benefits over and above any personal medical and hospitalization insurance available to my family. I understand that any personal medical and hospitalization coverage (subject to the exclusions, limitations, and provisions in the ministry's policy) may provide secondary or excess coverage. I agree to apply first for benefits from the personal hospitalization and medical coverages available to my family, if any, before applying for benefits that may be available from the ministry's medical and hospitalization coverage.

I further understand that, in the event that my child requires medical or dental treatment while engaged in any ministry activity, reasonable efforts will be made to contact my family; however, if they cannot be reached, I hereby consent and give permission to the ministry's sponsor or any adult counselor acting on behalf of the ministry with respect to the activity, as agent for me, to consent to any x-ray examination; injections; anesthesia; medical, dental, or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital.

To the best of my knowledge, I have listed above all of my child's medical issues, allergies, medications taken, and other pertinent information.
Participant's Name

First NameLast Name
Parent/Guardian Name

First NameLast Name
Signature

Clear
Should be Empty:

Permission & Medical Release Form

PERMISSION FORM

MEDICAL RELEASE

Emergency Contacts

Health History

Allergies