• Adult Medical Form

    NEHBC Student Ministry
  •  - -Pick a Date
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  • EMERGENCY CONTACT 1

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  • EMERGENCY CONTACT 2

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  • MEDICAL CARE

  • MEDICAL INSURANCE

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  • MEDICAL AUTHORIZATION

    In the event of a change in my medical condition, I will notify Northeast Houston Baptist Church (NEHBC) in writing. I understand that I can revoke this medical authorization at any time upon notice in writing to NEHBC.

    I hereby give permission to NEHBC and the physician selected by NEHBC representative to secure medical treatment that may be deemed necessary to ensure my well-being. I, the undersigned, do hereby release NEHBC from any and all claims, demands, actions or cause of action arising out of damage or injury while participating in NEHBC sponsored activities.

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