March 4, 2015
|Student Medical Release|
2012 Southside Baptist Church 709 9th Street Decatur, Alabama 35601 256-353-8814
Please print in ink
Name: ___________________________________________________ Age ________ Birthday ______________
LAST FIRST MIDDLEYear in school_________________ Male Female Email_____________________________________
Address_______________________________ City__________________ State ___________ Zip __________
Phone ___________________________________ Pager / cell__________________________________________
Medical insurance company_________________________ Policy #_______________________________________
Mother’s name__________________________________ Phone: Home_______________ Work______________
Father’s name___________________________________ Phone: Home_______________ Work______________
Emergency contact_______________________________ Phone: Home_______________ Work______________
Physician ________________________________________Office phone __________________________________
Dentist __________________________________________Office phone __________________________________
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 child’s 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
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:
Should this child’s activities be restricted for any reason? Please explain:
For your information, we expect each student to conform to these rules of conduct
No possession or use of alcohol, drugs, or tobacco
No students can drive
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
Participation with the group is expected
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: __________________
Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing miniature golf, hayrides. Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the church’s Youth Pastor prior to that event.
_____________________________ (NAME OF STUDENT) has my permission to attend all youth activities
sponsored by Southside Baptist Church (hereinafter the "Church") from January 1, 2012 to Dec. 31, 2012.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 child’s 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: __________________
The following is to be completed by the notary witnessing signature. The State of _________________ the County of __________________ Before me, a Notary Public, on this day personally appeared ___________________________
known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he/she executed the same for the purpose and consideration therein expressed.
Given under my hand and the seal of the office this ___________________________ day of ____________________, A.D. __________________________.
Notary Public, Signature
My Commission expires the ______________________ day of ___________________, A.D. ____________________.
|Last Updated ( Thursday, 19 April 2012 )|
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