Baltimore Medical Release

Baltimore Medical Release Form
July 9-16
Please print in ink
Childs Name: ______________________________________Age ___Birthday ___/____/______
LAST
FIRST
MIDDLE
Year in school____________ Male Female

Address _______________________________City_____________ State_____ Zip__________
Medical insurance company: ______________________________________________________
Policy #: ______________________________________________________________________
Mothers name_________________________________________________________________
Phone #s Home: ___________________Work:___________________ Cell:________________
Email:________________________________________________________________________
Fathers name:_________________________________________________________________
Phone #s Home:___________________ Work:___________________ Cell:________________
Email:_________________________________________________________________________
Other Emergency contact: ________________________________Relation to Child: __________
Phone #s Home:___________________ Work: ____________________Cell:_______________
Physician ________________________________________Office phone _________________
Dentist __________________________________________Office phone __________________
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity,
weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be
aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it
to this form. Include names of medications and dosages that must be taken.
Check the following areas of concern for this student. If necessary, add another page with details:
1. For your childs safety and our knowledge, is your student a
good swimmer fair swimmer non-swimmer
2. Does your child have allergies to
pollens medications________________________________________________________________________
food_______________________ insect bites _______________________
3. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma epilepsy / seizure disorder heart trouble diabetes
frequently upset stomach physical handicap Other____________________________________
4. Date of last tetanus shot: _____________
5. Does your child wear glasses contact lenses
6. Please list and explain any major illnesses the child experienced during the last year:
Additional comments:
Should this childs activities be restricted for any reason? Please explain:
Child #2 Name: ______________________________________Age ___Birthday ___/____/______

LAST
FIRST
MIDDLE

Child #3 Name: ______________________________________Age ___Birthday ___/____/______

LAST
FIRST
MIDDLE

For your information, we expect each student to conform to these specific rules of conduct
No possession or use of alcohol, drugs, or tobacco
No students can drive (Liability reasons prohibit this)
No fighting, weapons, fireworks, lighters, or explosives
No offensive or immodest clothing
No boys in girls sleeping quarters and no girls in boys sleeping quarters
No Purple, Public Displays of Affection among students
Participation with the group is expected
Respect property
Respect one another, staff, and adult leaders
Respect and comply with event schedules
Students who fail to comply with these expectations may be sent home at their parents expense.
I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth
group activities. I agree to abide by the stated personal limitations and code of conduct.
Student signature: _______________________________________Date: __________________
Note: If you desire to limit your childs participation in any event, please submit your wishes in writing to the church youth
pastor prior to that event.
I _______________________ give permission to Glenn View Baptist Church (hereinafter the Church) allowing them to
take my child on ALL YOUTH GROUP RELATED ACTIVITES. Giving them the right to transport my child to and from
destinations, to contact my child via social media/ through their cell phone by text messaging and calls, and taking and
posting appropriate pictures of them on social media/ promotion publications as the Youth Ministry sees fit. This consent
form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of
any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above,
a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that
there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors,
employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property
that may occur during the course of my/our childs involvement. In the event that he/she is injured and requires the
attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In
the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold
such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.
I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that
medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information
provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named
above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary
by the student ministries staff member.
Parent/guardian signature: _________________________________________ Date: _________

Baltimore Medical Release

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Baltimore Medical Release Form

Year in school____________ Male Female

Child #2 Name: ____________________________________Age _Birthday _//____

Year in school____________ Male Female

Child #3 Name: ____________________________________Age _Birthday _//____

Year in school____________ Male Female

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