Freedom Baptist Church Youth
Medical Release Form
987 US 1 Rockingham, NC 28379
Medical Release Form / Permission to Treat
Personal Information:
Student Full Name:
*
DOB:
*
Age:
*
Gender:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information:
Parent/Guardian:
*
Home Phone:
*
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Secondary Contact:
*
Relationship:
*
Home Phone:
*
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Insurance Information:
*Please attach a copy of your insurance card to this form.
Insurance Co.:
*
Group#:
*
Policy#:
*
Cardholder:
*
Relationship to Cardholder:
*
Insurance Co. Phone:
Format: (000) 000-0000.
Personal Medical Information:
Physician s Name:
*
Phone:
*
Format: (000) 000-0000.
Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc.):
List any medication we should know about.
Back
Next
The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. Emergency Authorization - I hereby give permission to medical personnel selected by the participants Church sponsor/his designee or camp staff to order X-rays, routine tests, and treatment for myself. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury. I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions.
Signature of Parent/Guardian
*
Date
*
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: