Faith Baptist Medical Release Form '24-'25

This Medical Release Form is valid from June 1, 2024 - June 1, 2025

Your name *

Email address *

Student Information

Student's Name *

First and Last

Gender *

Male

Female

Birth Date *

MM/DD/YYYY

Age *

min: 0 / max: 115

Address *

Include City, State, and Zip

Parent/Guardian Information

Parent/Guardian Name *

Best Contact Phone # *

Email Address *

Emergency Contact *

Emergency Contact Phone # *

Medical Information

Insurance Carrier *

Policy Number *

Name on Insurance Card *

Physician's Name *

Physician's Phone # *

Medical Info/Restrictions Leaders Should Know About *

If none, type N/A

Medications and Directions *

Safety Responsibility

It is the responsibility of camps and leaders to ensure the safety of all participants. An important part of ensuring safety is awareness of the unique needs and backgrounds of each participant.

Has your child faced any criminal charges through the juvenile justice system? *

If no, type No

Acknowledgement of Release

I hereby give my permission for myself or my child to participate in an activity organized by Faith Baptist Church. I hereby release, hold harmless, and absolve Faith Baptist Church, their staff, sponsors, vendors, and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively from responsibility and liability for any illness, injury, misadventure, harm, loss, or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Faith Baptist Church staff or any adult counselor acting on behalf of Faith Baptist Church with respect to the activity, to consent to any X-ray examination, medical, dental, or surgical diagnosis; treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child’s medical allergies, medications being taken, medical problems, and other pertinent information. Finally, I agree that Faith Baptist Church may video or photograph my child and record his or her voice during their participation in the activity. I agree that Faith Baptist Church will be able to use them; in whole or in part, whether in original or modified form in any manner or media, including without limitation, for the purpose of advertising, promoting, and publicizing Faith Baptist Church, whether during the activity or thereafter. I hereby release and discharge Faith Baptist Church and all affiliated entities from any and all claims, demands, or causes of action that I have in connection with the use and exercise of the rights granted in this release.

Parent/Guardian Name *

This acts as your signature

Date *

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