2026 Parental Consent, Med Authorization

2026 Annual Parental Consent, Certification, and Medical Authorization
Child’s Name
Date of Birth
Father
Home Phone
Work Phone
Email
Mother
Home Phone
Work Phone
Cell
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Email
Doctor’s Name
Telephone
Insured Name
Carrier
Policy #
Please send a copy of your updated insurance card.
Known Allergies, Medical Conditions
Medications or drugs taken regularly:
Please List Any OVER THE COUNTER Medications your child CANNOT take
LOCAL relative or friend to notify in case of an emergency and we cannot locate parent:
Name
Telephone
Is your child/student presently being treated for an injury or sickness or taking any medication?

YESNO
If yes, please explain.
Sleep Disorders
Does your child/student currently have or ever had the following: (Please mark all that apply:)

AsthmaHay FeverKidney DiseaseDiabetesHeart MurmerSeizure DisorderSleep DisorderOther
Child/Student blood type
It is my understanding that the church will attempt to notify me in case of a medical emergency involving my child. If the church cannot reach me, I authorize the church to seek professional medical care for my child. I give my permission to the doctor or other health-care professional to provide necessary medical services. I will pay for any medical expenses incurred. I will notify the church if I feel there are any health considerations that would prevent my child’s participation in an activity. I also give my permission for church leaders to restrict my child from participation in any activity which they have any question about for health or safety reasons. If a dispute over this agreement or any claim for damages arises, the process for reporting and resolution as outlined in the North Shelby Baptist Church Child Protection Policy shall be followed.

Clear
Signature of Parent or Legal Guardian
Date

MonthDayYear
Date
Once you've completed the form, please select "Submit." You're more than welcomed to "Preview PDF" and download or print for your records. You will receive a confirmation email from our office. If you do not receive the email, please feel free to contact us at your convenience.
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2026 Annual Parental Consent, Certification, and Medical Authorization

Sleep Disorders