Medical Release Form

Name of Student Attending *

First Name

Last Name

Phone Number (phone and sms capable preferred) *

(###)

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Date of Birth *

MM

DD

YYYY

Student's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1st Parent | Legal Guardian *

First Name

Last Name

Best Phone Number *

(###)

###

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2nd Parent | Legal Guardian *

First Name

Last Name

Best Phone Number *

(###)

###

####

Emergency Contact *

Other than parent/guardians listed

First Name

Last Name

Emergency Contact's Number *

(###)

###

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Family Doctor *

First Name

Last Name

Doctor's Phone Number *

(###)

###

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Insurance Company Phone Number *

(###)

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Policy Holder's Name *

First Name

Last Name

Date of last Tetanus Shot *

MM

DD

YYYY

Student May Be Administered *

Check all that apply.

Tylenol

Advil

Benadryl

Pepto Bismol

First Aid Cream/Spray

Neosporin

Date of Parent/Guardian Signature *

MM

DD

YYYY

Parent Legal Guardian Signature *

**By submitting this form, you consent to the participation in the above referenced activity conducted under the sponsorship of First Baptist Church, Forsyth County, Georgia. As parent, I hereby authorize and consent to any emergency medical treatment, including but not limited to X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to my child on the advice of a licensed physician, surgeon, anesthesiologist, dentist, or other qualified medical personnel acting under their supervision. I fully assume responsibility for any and all medical expenses which may be incurred.

First Name

Last Name