2013 Medical Release Form

Field Street Baptist Church
Student Ministry
2013 Medical Release Form
This is a one-time form that meets all medical release requirements for all Student Ministry activities for 2013
Name of Student/Participant:_____________________________________________________________________
Last
First
Sex:__________
Date of Birth:________________________
Age:________________
Address:_____________________________________________________________________________________
City, State, Zip Code:___________________________________________________________________________
Parent/Guardian Contact Information
Name:____________________________________________Home Phone:________________________________
Work Phone:_______________________________________Cell Phone:_________________________________
Other Emergency Contact Information
Name:____________________________________________Home Phone:________________________________
Phone #:__________________________________________
Current Medical & Insurance Information
Insurance Provider:__________________________________Policy Number:______________________________
Address:__________________________________________Phone:______________________________________
Name of Policy Holder:_________________________________________________________________________
Family Physicians Name:_____________________________Phone #:___________________________

List any medical difficulties in which your child is CURRENTLY being treated: ____________________
_____________________________________________________________________________________
List any medications and dosage your child is CURRENTLY being treated:________________________
_____________________________________________________________________________________
Are there any known allergies to food or medications: [ ] Yes [ ] No
If yes, please explain:_______
_____________________________________________________________________________________
Are there any known medical or health problems, chronic or recurring illness or illnesses that could affect
your childs participation? [ ] Yes [ ] No
If yes, please explain:______________________________
_____________________________________________________________________________________
Date of last tetanus shot:
________________/______
Are there any activities, such as strenuous activities, to be restricted for your child? [ ] Yes [ ] No
If yes, please explain:___________________________________________________________________
Can you swim: [ ] Yes [ ] No
Other comments or suggestions from the parent or guardian concerning your child:__________________
_____________________________________________________________________________________
I understand that any personal medical and hospitalization insurance available to my family will provide
primary coverage and the ministrys medical and hospitalization coverage (subject to the exclusions,
limitations and provisions in the ministrys policy) may provide secondary or excess coverage. I agree to
apply first for benefits from the personal hospitalization and medical coverage available to my family, if
any, before applying for benefits that may be available from the ministrys medical and hospitalization
coverage.
I further understand, that, in the event my child requires medical or dental treatment while engaged in
activities with Field Street Baptist Church, reasonable efforts will be made to contact me; however, if I
cannot be reached, I hereby consent and give permission to the ministrys sponsor or any adult counselor
acting on behalf of the ministry with respect to church activities, as agent for me, to consent to any x-ray
examination; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and hospital care
and treatment 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 childs medical allergies,
medications being taken, medical problems and other pertinent information. My child has permission to
participate in all prescribed activities except as noted by me. I realize that this medical release form is
valid for one (1) calendar year from the date below. If there are any changes, I will notify Field Street
Baptist Church.
Signature of Parent/Guardian:______________________________________________ Date:_______________
..
STATE OF TEXAS
COUNTY OF JOHNSON
BEFORE ME, A NOTARY PUBLIC, on this day personally appeared___________________________,
Known to me to be the person whose name is subscribed to the foregoing document, and being by me first
duly sworn declared that the statements therein contained are true and correct.
GIVEN UNTO MY HAND AND SEAL OF OFFICE this, the _______day of____________, 2013.
_____________________________________
Notary Publics Signature
_____________________________________
Printed or typed name of Notary

2013 Medical Release Form

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Field Street Baptist Church

Family Physicians Name:___Phone #:_

If yes, please explain:_______

If yes, please explain:______________________________

Signature of Parent/Guardian:________________________________ Date:_

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