Youth Medical Release Form and Medical Information 2020

Student's Name

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Parent/Guardian Full Name

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I The Parent/Guardian named above, authorize that the staff and/or adult volunteers of the First Baptist church may seek or provide medical assistance for the child named above, in the case of an emergency during any regularly sponsored youth event or activity from January 1, 2020 - December 31st, 2020

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Medical Information

Name of Student

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Date of Birth

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Personal Doctor

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Personal Doctor Phone

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Medical Insurance Company

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Medical Insurance Policy Number

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Parent/Guardian Contact Information

Name

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Cell Phone

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Home Phone

Work Phone

Other Emergency Contact

Name

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Cell Phone

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Home Phone

Work Phone

Medical History

Allergies to Food

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Allergies to Medication

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Current Medications (Include vitamins, herbs, and "As Needed" Medications)

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(All medications brought must be labeled with the drug name, student's name, dose size, and frequency of us.)

Description

Please fill out this form and click submit.