Permission and Medical Release Form Rock Springs Baptist Church

Permission and
Medical Release Form
Name:
_
Address:_______________________________________
for
City, State:
Rock Springs Baptist Church
Easley, SC
DOB:
Zip:
Age:
Grade:
Phone Number:_________________________________
I grant my permission for my son/daughter to participate fully in children/student ministry activities from September 1, 2013August 31, 2014, which Rock Springs (hereinafter referred to as "the church") is sponsoring or in which it is participating. Further,
permission is hereby given to the church to furnish any necessary transportation (within the limitations of church insurance and the
law), food and lodging for my son/daughter. I also grant permission to the church leadership to seek a doctor or qualified person to
provide emergency medical treatment to the above named student in the event he/she is ill or injured while participating in or traveling
to and from any church activity during the year. I do hereby authorize and consent to any reasonable medical treatment as deemed
necessary by a licensed physician. It is understood that this authorization is given in advance of any specific diagnosis or treatment being
required, but is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment,
may deem advisable. It is also understood that effort will be made to reach his/her emergency contact, prior to rendering treatment, but
that any of the above treatment will not be withheld if the emergency contact cannot be reached.
I understand the nature of all church events and do hereby release Rock Springs Baptist Church, its staff and representatives, and
any other entities, their staff and representatives that are involved for any particular event, from any liability for accidents or injury
sustained by my child in conjunction with student ministry activities.
Medical Information
(Please submit a copy, front and back, of your insurance card)
Insurance Carrier:____________________________________________________________________________________
Policy Holder:_____________________________ Policy Number:____________________________________________
Family Doctor:______________________________________________________________________________________
Has your child had an appendectomy?
Has child had a DPT shot?
Has child had a tetanus shot?
Does your child have any allergies?
Yes
Yes
Yes
Yes
No
No
No
No
If yes, date of tetanus shot:______________________________
If yes, list allergies:
_________________________________________________________________________________________________________
Does your child have any physical or mental handicap, illness, or other problem that we should be aware of?
Yes No
If yes, please list:_________________________________________________________________________________________
Staff members/volunteers have permission to administer as necessary: Tylenol
Imodium
Advil
Motrin
Cough Drops
Antacids
(On back, please list any medications your child takes on a regular basis.)
Signature of Parent/Guardian:
Date:
_
In case of emergency, I can be reached at the following telephone numbers:
Home Phone:
Cell Phone:
Work Phone:
Alternative Person to Contact:
Name:
Phone:
Relationship:
_
Medicines Taken
Medicine
Dosage
Frequency
Media Release
I,_______________________________________________,hereby give permission for the staff and volunteers
of Rock Springs Children/Student Ministries to photograph, videotape, and/or voicetape my child (or allow
area news reporters to do the same) for purposes of in-house church use and/or public information for
promotion of the church (i.e. brochures, website(s), newspapers, radio, television). I also understand that
my child will not be identified by name.
Parent/Guardian Signature:
Date:
_