2015-2016 Medical Release Form

2015-2016 Taylors First Baptist Church Worship Ministry Permission & Medical Release Form
Student’s Name:
Birthdate:
Grade:
*Student’s Social Security Number:
Doctor’s Name & Phone Number:
Allergies:
Medications Currently Taking:
Parent’s/Guardian’s Name:
Parent’s/Guardian Birthdate:
*Parent’s/Guardian’s Social Security Number:
Place of Employment:
Home Address:
City/State/Zip:
Home Phone #:
Parent Cell Phone #:
Emergency Contact Name (other than parent) & Contact #:
Insurance Company:
Policy #:
*Please be informed that in the event of an emergency, medical care may be refused by hospital/doctor if social security numbers are not included on this form.
General Release/Hold Harmless Agreement
As the parent or legal guardian of the above student:
1) I acknowledge that the student above desires to participate in the programs, events or activities (hereinafter collectively referred to as
“Activities”) operated, sponsored or attended by Taylors First Baptist Church (hereinafter referred to as the “Church”) and Taylors Worship of
Taylors First Baptist Church.
2) I acknowledge that participating in the activities operated, sponsored or attended by the Church and Taylors Worship will frequently involve
transportation to and from various locations.
3) I hereby give consent for the above student to participate in the Activities and authorize the Church and Taylors Worship to transport the
above student to and from various locations for the activities.
4) I give permission for the above student to ride in any vehicle, deemed suitable by the adult in whose care the above student has been
entrusted, while attending and participating in activities operated, sponsored or attended by the Church and Taylors Worship.
5) In the event the above student is injured while participating in activities or while being transported, I do hereby authorize and consent to any
X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care rendered under the general
supervision and the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a
licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
6) I acknowledge the undersigned shall be liable and agree to pay all cost and expenses incurred in connection with any such medical and
dental services rendered to the above student pursuant to this Authorization.
7) I understand that should it be necessary for the above student to return home due to medical reasons or otherwise, the undersigned shall
assume all transportation costs.
8) In consideration of the Church and Taylors Worship allowing the above student to participate in activities, I do hereby release and forever
discharge the Church, Taylors Worship, their officers, director, employees, agents and any parties volunteering on behalf of the Church or
Taylors Worship from all actions, claims, damages, costs, expenses, or damages of any nature whatsoever arising from or in connection with
participation in or transportation to or from activities.
9) As the undersigned, I understand it is my responsibility to update the Emergency Information contained in this Permission & Medical Release
Form as necessary.
10) I consent and give my permission for the Church and Taylors Worship to use any photographs and/or videos of the above student for
use in Taylors Students and/or any promotional material for the Church and Taylors Worship
**DO NOT SIGN BELOW UNTIL NOTARY IS PRESENT.**
Signature of Parent/Guardian
Print Name of Parent/Guardian
Notary Public
Witness my hand & official seal this date:
On this date the person(s) who are signed above
personally appeared before me in my presence
and executed this authorization and medical
release form.
Notary Signature & Date
Date My Commission Expires
Date
NOTARY SEAL