Minor Mission Participation Agreement (2019-2020)

Minor Mission Participation Agreement (2019-2020)

Please fill out the attached form and sign where prompted. This form MUST be received by a Ministry Leader of Spring Hills Baptist Church (Spring Hills) before the minor listed on this form may participate in any event sponsored by Spring Hills. This Participation Agreement Form covers the term of March 1, 2019 - May 31, 2020.
Event Name
Personal Information
Participant's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Preferred Phone Number *
Home Mobile
Preferred Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
Allergies or Medical Conditions: *
Preferred Emergency Contact Information
Name *

First Name Last Name
Relationship *
Phone Number *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
Secondary Emergency Contact Information

In the case that the Primary Emergency contact cannot be reached
Name *

First Name Last Name
Relationship *
Phone Number *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
Permissions
Participant's Name *

First Name Last Name
Participant's Signature *

Clear
Parent/Legal Guardian's *

First Name Last Name
Parent/ Legal Guardian's Signature *

Clear
AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT:

The undersigned consents:

1. The administration of any treatment deemed necessary by:
Preferred Physician
Preferred Physician's Phone Number
Preferred Dentist
Preferred Dentist Phone Number
OR in the event the appropriate specified practitioner is NOT available, by another licenced physician or dentist:

2. The transfer of minor to preferred hospital or any hospital reasonably accessible.
Preferred Hospital *
3. This authorization does not cover major surgery unless the medical opinions of
two other licensed physicans or dentists concurring in the necessity for such surgery are obtained in writing prior to the performance of such surgery.
I AGREE *
Initial Here
Date

Month Day Year
Date
Medical Insurance Carrier *
Policy Number *
PRINT PARENT'S NAME *

First Name Last Name
PARENT/LEGAL GUARDIAN'S Signature *

Clear
Should be Empty:

Minor Mission Participation Agreement (2019-2020)

Personal Information

Preferred Emergency Contact Information

Secondary Emergency Contact Information

Permissions