Medical/Permission and
Liability Release Form
Name________________________________________________Date of Birth______/______/______
Address____________________________________City__________________State____Zip_______
In Case of Emergency Notify:____________________________________Phone_________________
Family Physician______________________________________________Phone_________________
Insurance Co.________________________________Policy#______________Group#____________
(Please Attach a copy of your family insurance card to this form)
Any current medications: (List)_______________________________________________________
Drug or Food Allergies: (List)_________________________________________________________
Significant Medical Problems: ________________________________________________________
PERMISSION FOR TREATMENT AND RELEASE OF LIABILITY
I, _____________________________________________________, am the parent or legal guardian of
_______________________________________(hereinafter “my child”). I understand that in the event
of a medical emergency, in case of injuries, accidents or illness, I give my permission for any treatment
deemed necessary in consultation between the attending emergency physician and the adult
representative of First Baptist Church Sevierville. I understand and do hereby verify that the above
information is correct, and I do hereby release and forever discharge all sponsors and First Baptist
Church Sevierville from any and all claims, demands, actions or cause of action, past, present or future
arising out of any damage or injury while participating in this church activity.
Notary Acknowledgement (Notary: Please affix seal)
Dated this _________day of____________________, 20____
State of ________________, County of ________________
Signature_________________________________________(Parent Signature)
Personally appeared before me, ___________________________________, with whom I am
personally acquainted, and in my presence executed the within and foregoing permission and release
form.
Witness my hand and official seal this _______day of____________________, 20____.
Notary Public_____________________________________
My Commission Expires:____________________________
Notary Signature:__________________________________________
My commission expires:___________________________