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    Towerview Medical Release Form

    Uploaded by

    Cody Hudspeth
    This medical release form collects contact and insurance information for a student attending events at Towerview Baptist Church. It grants permission for medical treatment if the student becomes sick or injured, and releases the church from any liability. The student and their parent/guardian must both sign agreeing to the terms of the form including permission for emergency medical care if parents cannot be reached.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Towerview Medical Release Form

    Uploaded by

    Cody Hudspeth
    65 views3 pages
    This medical release form collects contact and insurance information for a student attending events at Towerview Baptist Church. It grants permission for medical treatment if the student becomes sick or injured, and releases the church from any liability. The student and their parent/guardian must both sign agreeing to the terms of the form including permission for emergency medical care if parents cannot be reached.

    Original Description:

    Towerview Baptist church medical release form

    Copyright

    © © All Rights Reserved

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    This medical release form collects contact and insurance information for a student attending events at Towerview Baptist Church. It grants permission for medical treatment if the student becomes sick or injured, and releases the church from any liability. The student and their parent/guardian must both sign agreeing to the terms of the form including permission for emergency medical care if parents cannot be reached.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    65 views3 pages

    Towerview Medical Release Form

    Uploaded by

    Cody Hudspeth
    This medical release form collects contact and insurance information for a student attending events at Towerview Baptist Church. It grants permission for medical treatment if the student becomes sick or injured, and releases the church from any liability. The student and their parent/guardian must both sign agreeing to the terms of the form including permission for emergency medical care if parents cannot be reached.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Towerview Baptist Church

    Student

    Medical Release Form


    Name:
    Birth Date:

    Age:

    Social Security #:

    Sex: Male / Female

    Address:

    Contact

    City:

    State:

    Zip:

    Parent / Guardian:
    Name:
    Home Phone: (

    Work Phone: (

    Other person to notify in event of emergency:


    Their relationship to you:

    Important

    This persons phone number Daytime: (

    Evening: (

    Please supply ALL of the following information. Please attach a copy of your insurance card.
    Medical Insurance Company:

    Group #:

    Policy #:

    Insured Policy Holders Name (Adult):


    Insured Policy Holders Birthdate (Adult):
    Company Address:
    City:

    Company Phone: (
    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 Towerview Student ministry
    events(Prescription medications MUST have pharmacy label and name of doctor):

    Agreement

    Continued on Back
    Release - Permission for Medical Treatment, Photograph/Video Notice, and Release and IndemnityMy permission is granted for the Pastor, church official, any event staffer, or adult present or in charge of
    First Aid, to obtain necessary medical attention in case of sickness or injury to my child. Also, I
    understand that as a participant, my child may be photographed or videotaped during event activities and
    these photos/videos may be used in promotional materials. I, the undersigned, do hereby verify that the
    above information is correct and I do hereby release and forever discharge Towerview Baptist church,
    event sponsors from any and all claims, demands, actions or causes of action, past, present, or future
    arising out of any damage or injury while participating in this camp or event. I agree to indemnify
    Towerview Baptist church for any and all claims, demands, damages, injuries, costs, suits or causes of
    action, past, present, or future, arising out of or caused by my child while participating in ministry event
    or while on property leased or owned by Towerview Baptist church. Complete and sign below (youth
    under 18 years of age requires Parent/Legal Guardian signature)

    In the event I cannot be reached in an emergency, I hereby give permission for the physician selected by Towerview
    Baptist church staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, x-ray or surgery for
    my child named above.

    Students Signature_________________________________________________
    Parent/Guardian Signature

    Date

    Date

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