HABC Medical Release & Permission Form
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Name: Last, First, Middle *
Age *
Birthdate: *
Grade: *
Student's Gender
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Student's email:
Address: *
Student's Phone Number
Mother's Name:
Mother's Phone Number:
Father's Name:
Father's Phone Number:
Emergency Contact:
Medical Insurance Company/Policy # *
Physician's Name & Phone Number: *
Dentist's Name & Phone Number: *
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your student is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing below. Include names of medications and dosages that must be taken.
Please explain any medical history as stated in the above paragraph. If none, please indicate none. *
For your student's safety and our knowledge is your student a: *
Does your student have allergies to: *
Does your student suffer from, or has he/she ever experienced, or is he/she being treated currently for any of the following: *
Date of last tetanus shot: *
Does your student wear: *
Please explain or list and major illnesses the student experienced during the last year. If none, indicate none. *
Please explain or list any activities from which your student should be restricted.
Student's Consent
For your information, we expect each student to conform to these rules of conduct:
No possession or use of alcohol, drugs, or tobacco
No fighting, weapons, fireworks, lighters, or explosives
No offensive or immodest clothing
No boys in girls' sleeping quarters and no girls in boys' sleeping quarters
Participation with the group is expected
Respect property
Respect one another, staff, and adult leaders
Respect and comply with event schedules
Respect off limits areas at all times
Respect all location mandates and ordinances
No public displays of affection
Always keep a good attitude
Pack appropriately
By typing my name below, I, the student, consent and agree to all the above information and code of conduct. *
Parental Consent
I, the parent, give my permission for the above child to attend all church activities sponsored by Holland Avenue Baptist Church. Activities include - but are not limited to - off-campus Bible studies, day trips out of town or in town, overnight trips out of town or in town, and summer camp. (If you desire to limit your student's participation in any event, please submit your wishes in writing to the church prior to the event.)
I certify that I have read and agree to the above terms regarding my student's activity involvement. *
Medical Release Consent
This consent statement gives permission to seek whatever medical attention is deemed necessary and releases Holland Avenue Baptist Church and its staff of any liability against personal losses of named student.

I/We the undersigned have legal custody of named above, a minor, and have given our consent for him/her to attend events organized by Holland Avenue Baptist Church (HABC). I/We understand that there are inherent risks involved in any ministry or fellowship event, and I/We hereby release HABC, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the natural course of the student's involvement. In the event that he/she is injured and requires medical attention, I/We consent to any reasonable medical treatment as deemed necessary by a licensed medical professional. In the event treatment is required from a physician and/or hospital personnel designated by HABC, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that I/we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring the student home at my/our own expense should the student become ill or if deemed necessary by the student ministries staff member.
I certify I have read and agree to the above terms. *
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