Western Heights Baptist Church Medical Release Form 2018
Children's Ministry Medical Release form for Western Heights Baptist Church
This form is valid from January 1, 2018 - December 31, 2018.
Email address *
Child's first and last name *
Your answer
Male/female *
Child's date of birth *
MM
/
DD
/
YYYY
Child's age/grade *
Parent/guardian first and last name *
Your answer
Address line 1 *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Best phone number *
Your answer
Alternate phone number
Your answer
If parent/guardian is not available in an emergency, notify *
Your answer
Relationship of emergency contact to child *
Your answer
Emergency contact phone number *
Your answer
Additional emergency contact name
Your answer
Relationship of additional emergency contact to child
Your answer
Additional emergency contact phone number
Your answer
Does this child have any of the following allergies? *
Required
Food allergies? If so, what?
Your answer
Any other allergies? If so, what?
Your answer
Does this child have any medical or health problems/conditions, and or has this child had any chronic or recurring illness or illnesses *
If yes, please describe the problems or illnesses
Your answer
Child's family physician *
Your answer
Physician's phone number *
Your answer
Describe any dietary restrictions this child is required to follow
Your answer
List any physical restrictions that would limit participation in any activities
Your answer
Date of child's last tetanus shot
Your answer
Is there medical or hospitalization insurance which provides benefits for this child? *
Name of insurance company
Your answer
Phone number
Your answer
Policy holder's full name
Your answer
Policy number
Your answer
Group number
Your answer
In the event that medical care is required during the time period specified above, I (we) hereby grant permission for the appropriate staff member or adult sponsor of Western Heights Baptist Church, Waco, Texas, to secure medical care for my (our) child, and I (we) hereby grant the physician(s) permission to provide any and all medical care necessary (including examination, diagnosis, anesthesia, medical , hospital, and surgical procedures or treatments) for my child's well-being. I (We), the undersigned parent(s) and/or guardian(s) of the above child, do hereby release, acquit, discharge, and hold harmless Western Heights Baptist Church and its representatives, from any and all damages and liabilities arising out of the medical care provided to my (our) child under this Medical Authorization. I (We) understand the Western Heights Baptist Church and its representatives shall incur no liability whatsoever while attending to the medical needs of my (our) child and for obtaining medical care for my (our) child as they deem appropriate. If only one parent or guardian signs this instrument such individual hereby represents that he or she has obtained the other parent's or guardian's agreement to the terms of this instrument.
Parent/Guardian signature *
Your answer
Parent/Guardian signature
Your answer
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