FIRST BAPTIST CHURCH YOUTH ACTIVITIES
MEDICAL RELEASE & PERMISSION FORM
Date:
_______________________
Event: ______________________________________
Name: _____________________________________________________________________________
Birth Date: ____/____/_____ Age: _____
Address:
City:
Social Security #: ___________________Sex (M/F)______
_______________________________________________________________________
______________________________ State: _________________Zip: ____________________
Parent/Guardian_____________________________________________________________________
Home phone: (
)
Work Phone: (
)_____________________
Other person to notify in event of emergency______________________________________________
Relationship to you________________________________________________________________
This person’s phone number: Daytime (
)
Evening (
)___________ Cell ____________________
Please supply ALL of the following information and attach a copy of your insurance card.
Medical Insurance Company _________________________Group #_______Policy#______________
Company’s Address ______________________________Company’s Phone (
City:
)_________________
________________________________________________State: __________ Zip: _________
Physical Limitations (Asthma, diabetes, allergies, etc), and/or special instructions (Allergic to certain medications, rare
blood type, wears contact lens, etc.)________________________________________
____________________________________________________________________________________
List all medication you take on a regular basis and/or any you bring with you to all youth activities. (Prescription
medications MUST have pharmacy label and name of doctor):_______________________
____________________________________________________________________________________
Date of last Tetanus Shot______________________________________________________________
Youth has permission to take OTC medication such as Tylenol, Ibuprofen, ect.
_________________________________________________________________
(Parent Signature)
Youth has permission to engage in all scheduled activities planned by the youth sponsors of FBC.
(Parent Signature)
In the event I cannot be reached in an emergency, I hereby give permission for the physician selected by the First Baptist
staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child named above.
I understand that if youth do not follow the rules/guidelines of the youth sponsors, I will be responsible to come
and get them and they will not be allowed to continue with the activity/trip.
Signed:_____________________________________________________________________________
Date: __________________________________
Relationship:_____________________________________