Medical Release Form Fall 2018-Summer 2019
First Baptist Church Portland, Tx Student Ministry Release Form for Student Events
Student Name *
Your answer
Birth Date *
MM
/
DD
/
YYYY
School Grade *
Address *
Your answer
Phone *
(student phone)
Your answer
Parent or Legal Guardian Name *
Your answer
Phone *
(parent or guardian phone)
Your answer
email address
Your answer
In an emergency notify (Relationship) *
Your answer
Phone *
(emergency contact)
Your answer
If unavailable notify (Relationship) *
Your answer
Phone *
(for secondary contact)
Your answer
Insurance Company *
Your answer
Policy Number *
Your answer
Group or Member Number *
Your answer
Does the student have any allergies? *
If Yes, list all allergies (start with any medication allergies) *
Your answer
Please list any other physical difficulties or conditions to which we should be alerted. *
Your answer
Name of any regular medications *
Your answer
Immunization for? *
Required
In Case of Medical Emergency (e signature) *
I hereby give permission for my child to attend and participate in the First Baptist Church Student Ministry. I understand that, in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give my permission to the sponsors in charge to secure medical treatment.
Your answer
Date *
(date of signature)
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of First Baptist Church, Portland. Report Abuse - Terms of Service