Medical Information Form

**ONLY FILL OUT IF YOU HAVEN'T YET EVER DONE SO...IF YOU HAVE FILLED THIS OUT IN THE PAST YOU CAN SKIP THIS.**
Medical Release Form 2021 - 2022
Name

First NameLast Name
Birth Date

MonthDayYear
Age
Gender

MaleFemale
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian

First NameLast Name
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
Secondary Contact in event of emergency

First NameLast Name
Their relationship to you / Phone

RelationPhone Number
Medical insurance details
Medical Insurance Co

Group #

Policy #
Company's address

Company's Phone

CityState

Zip
Family Physician
Name
Phone Number
Physical Limitations (Asthma, diabetes, allergies, etc.), and/or special instructions (Allergice to certain meds, rare blood type, wears contact lenses, etc.)
List ALL medication taken on a regular basis (Prescription meds MUST have a pharmacy label and name of doctor)
Any swimming, activity, or other restrictions
Date of last Tetanus Shot
Medical Release: "In the event that I cannot be reached in an emergecny during the time period on this form, I hereby give permission to the physician or dentist selected by the leadership to hospitalize, secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary."
Liabilty Release: "Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activites. They also agree not to hold this church or its employees or volunteer assistants liable for damages, losses or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release."
"I understand and hereby grant First Baptist Church Youth Ministry, its staff and leaders permission, that, while my child is participating in approved Youth Ministry activities, photographs and videotape of my child may be taken for use in promoting First Baptist Church Youth Ministry."

YesNo
Signature

Clear
Should be Empty:

**ONLY FILL OUT IF YOU HAVEN'T YET EVER DONE SO...IF YOU HAVE FILLED THIS OUT IN THE PAST YOU CAN SKIP THIS.**

Medical Release Form 2021 - 2022

Medical insurance details

ONLY FILL OUT IF YOU HAVEN'T YET EVER DONE SO...IF YOU HAVE FILLED THIS OUT IN THE PAST YOU CAN SKIP THIS.